Healthcare Provider Details

I. General information

NPI: 1558012617
Provider Name (Legal Business Name): JENNIFER MARIE NEVADOMSKI LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2022
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

687 STRAITS TPKE STE 1C
MIDDLEBURY CT
06762-2846
US

IV. Provider business mailing address

67 SHANE DR
SOUTHBURY CT
06488-2678
US

V. Phone/Fax

Practice location:
  • Phone: 203-408-2420
  • Fax:
Mailing address:
  • Phone: 516-204-2310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5350
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: