Healthcare Provider Details

I. General information

NPI: 1710101191
Provider Name (Legal Business Name): JENNIFER LYNN DOUTRE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 06/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 CENTER ST
MANCHESTER CT
06040
US

IV. Provider business mailing address

2 WATERSIDE XING STE 401
WINDSOR CT
06095-1587
US

V. Phone/Fax

Practice location:
  • Phone: 860-646-3888
  • Fax: 860-645-4132
Mailing address:
  • Phone: 860-697-3351
  • Fax: 860-731-5536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number006417
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: