Healthcare Provider Details

I. General information

NPI: 1477121341
Provider Name (Legal Business Name): JASON C BEDFORD LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2021
Last Update Date: 06/16/2021
Certification Date: 06/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 WASHINGTON AVE
NORTH HAVEN CT
06473-1123
US

IV. Provider business mailing address

168 NORTONTOWN RD
MADISON CT
06443-1924
US

V. Phone/Fax

Practice location:
  • Phone: 203-836-6570
  • Fax:
Mailing address:
  • Phone: 203-836-6570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number001409
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: