Healthcare Provider Details

I. General information

NPI: 1164877312
Provider Name (Legal Business Name): PATRICIA MARIE JENKINS-SIMMONS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2016
Last Update Date: 04/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 WILLIAM ST 1ST FLOOR
NEW HAVEN CT
06511-4939
US

IV. Provider business mailing address

54 WILLIAM ST 1ST FLOOR
NEW HAVEN CT
06511-4939
US

V. Phone/Fax

Practice location:
  • Phone: 203-676-7617
  • Fax:
Mailing address:
  • Phone: 203-676-7617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number009136
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number009136
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number009136
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: