Healthcare Provider Details

I. General information

NPI: 1629961123
Provider Name (Legal Business Name): JENNIFER A PROFFITT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2025
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 FOREST PARK DR STE 2-2-LM
FARMINGTON CT
06032-1445
US

IV. Provider business mailing address

500 OLD FARMS RD
AVON CT
06001-2716
US

V. Phone/Fax

Practice location:
  • Phone: 860-383-7090
  • Fax:
Mailing address:
  • Phone: 860-919-3210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number231
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: