Healthcare Provider Details

I. General information

NPI: 1649902214
Provider Name (Legal Business Name): JESSICA VANDERBERG LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2022
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 PECK RD
BETHANY CT
06524-3322
US

IV. Provider business mailing address

4 PECK RD
BETHANY CT
06524-3322
US

V. Phone/Fax

Practice location:
  • Phone: 646-283-3857
  • Fax:
Mailing address:
  • Phone: 646-283-3857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number014422
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: