Healthcare Provider Details

I. General information

NPI: 1932032554
Provider Name (Legal Business Name): JACQUELINE GIM YEU LASLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 N MAIN ST STE 203
BRISTOL CT
06010-4993
US

IV. Provider business mailing address

225 N MAIN ST STE 203
BRISTOL CT
06010-4993
US

V. Phone/Fax

Practice location:
  • Phone: 860-506-7905
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number12189
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: