Healthcare Provider Details

I. General information

NPI: 1306385802
Provider Name (Legal Business Name): JENNIFER T BETHEA LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2017
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

352 STATE ST
NORTH HAVEN CT
06473-3108
US

IV. Provider business mailing address

1 LONG WHARF DR STE 321
NEW HAVEN CT
06511-5946
US

V. Phone/Fax

Practice location:
  • Phone: 203-781-4600
  • Fax: 203-781-4624
Mailing address:
  • Phone: 203-781-4600
  • Fax: 203-781-4624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1672
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: