Healthcare Provider Details

I. General information

NPI: 1275130320
Provider Name (Legal Business Name): JILL D BUKOWSKI LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2020
Last Update Date: 02/15/2023
Certification Date: 02/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

353 MCCLINTOCK ST
NEW BRITAIN CT
06053-2018
US

IV. Provider business mailing address

353 MCCLINTOCK ST
NEW BRITAIN CT
06053-2018
US

V. Phone/Fax

Practice location:
  • Phone: 860-797-5812
  • Fax:
Mailing address:
  • Phone: 860-797-5812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number2478
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number2968
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: