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General NPI Number Information
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NPI Number | 1063956316
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Entity Type | Organization
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Legal Business Name | JCALLENMD, LLC
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Dates
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Enumeration Date | 12/06/2016
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Last Update Date | 12/06/2016
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Provider Practice Location Address
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Address Line | 765 E MAIN ST
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City | BRANFORD
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State | CT
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Zip | 06405-2922
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Country | US
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Telephone | 860-378-7841
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Fax |
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Provider Business Mailing Address
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Address Line | 106 CONCORD DRIVE
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City | MADISON
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State | CT
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Zip | 06443-2560
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Country | US
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Telephone | 860-378-7841
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Fax |
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Authorized Official
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Title or Position | CEO/PRESIDENT
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Name | DR. JONATHAN CRAIG ALLEN
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Credential | MD
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Telephone | 860-378-7841
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 041054
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License Number State | CT
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