Healthcare Provider Details

I. General information

NPI: 1871269639
Provider Name (Legal Business Name): JESSICA ANN FIDLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2021
Last Update Date: 08/20/2021
Certification Date: 08/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 STRAWBERRY HILL AVE
STAMFORD CT
06902-2608
US

IV. Provider business mailing address

1425 BEDFORD ST APT 3P
STAMFORD CT
06905-5224
US

V. Phone/Fax

Practice location:
  • Phone: 203-977-5489
  • Fax:
Mailing address:
  • Phone: 609-439-5637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4793
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: