Healthcare Provider Details

I. General information

NPI: 1033638457
Provider Name (Legal Business Name): JESSICA MARKS, LPC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2017
Last Update Date: 09/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 MAIN ST # C
NEW HARTFORD CT
06057-2748
US

IV. Provider business mailing address

360 RIVERTON RD
RIVERTON CT
06065-1102
US

V. Phone/Fax

Practice location:
  • Phone: 860-485-5536
  • Fax:
Mailing address:
  • Phone: 860-485-5536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. JESSICA MARKS
Title or Position: SOLE PROPRIETOR
Credential: LPC
Phone: 860-485-5536