Healthcare Provider Details

I. General information

NPI: 1902077878
Provider Name (Legal Business Name): JENNIFER A BLAKESLEE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2008
Last Update Date: 03/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 CRESCENT ST MIDDLESEX HOSPITAL FAMILY ADVOCACY
MIDDLETOWN CT
06457
US

IV. Provider business mailing address

28 CRESCENT ST MIDDLESEX HOSPITAL FAMILY ADVOCACY
MIDDLETOWN CT
06457
US

V. Phone/Fax

Practice location:
  • Phone: 860-358-3401
  • Fax: 860-358-3403
Mailing address:
  • Phone: 860-358-3401
  • Fax: 860-358-3403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number006611
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: