Healthcare Provider Details

I. General information

NPI: 1437454717
Provider Name (Legal Business Name): JACQUELINE GUAJARDO PH.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2011
Last Update Date: 07/08/2021
Certification Date: 07/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 WOODLAND ST
HARTFORD CT
06105-1207
US

IV. Provider business mailing address

99 WOODLAND ST
HARTFORD CT
06105-1207
US

V. Phone/Fax

Practice location:
  • Phone: 860-714-4212
  • Fax: 860-714-8080
Mailing address:
  • Phone: 860-714-4212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number002876
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number7187181
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: