Healthcare Provider Details

I. General information

NPI: 1083349880
Provider Name (Legal Business Name): JACOB JAMES CARPENTER MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2022
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 CHARTER RD
WETHERSFIELD CT
06109-4307
US

IV. Provider business mailing address

77 CHARTER RD
WETHERSFIELD CT
06109-4307
US

V. Phone/Fax

Practice location:
  • Phone: 802-380-9473
  • Fax:
Mailing address:
  • Phone: 802-380-9473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number14499
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: