Provider Demographics
NPI:1881176295
Name:POTTER, JENNIFER MCCALL (LICSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MCCALL
Last Name:POTTER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 LENISTON ST
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-4008
Mailing Address - Country:US
Mailing Address - Phone:617-676-8711
Mailing Address - Fax:
Practice Address - Street 1:175 N BEACON ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-2790
Practice Address - Country:US
Practice Address - Phone:617-676-8711
Practice Address - Fax:617-972-7665
Is Sole Proprietor?:No
Enumeration Date:2018-08-31
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1165471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical