Healthcare Provider Details

I. General information

NPI: 1265913859
Provider Name (Legal Business Name): JODINE WAUCHOPE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2018
Last Update Date: 03/09/2023
Certification Date: 03/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 ALBANY AVE
HARTFORD CT
06105-1001
US

IV. Provider business mailing address

1680 ALBANY AVE
HARTFORD CT
06105-1001
US

V. Phone/Fax

Practice location:
  • Phone: 860-236-4511
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number130661
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11732
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: