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General NPI Number Information
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NPI Number | 1093115974
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Entity Type | Individual
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Provider Name | JACKIE SMALL MA, LPC, CLC
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Gender | Female
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Dates
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Enumeration Date | 08/28/2014
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Last Update Date | 03/31/2017
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Provider Practice Location Address
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Address Line | 1 TURKEY HILL RD S SUITE 2L
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City | WESTPORT
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State | CT
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Zip | 06880-5525
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Country | US
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Telephone | 646-246-7379
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Fax |
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Provider Business Mailing Address
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Address Line | 1 TURKEY HILL RD S SUITE 2L
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City | WESTPORT
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State | CT
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Zip | 06880-5525
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 3158
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 174N00000X
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Taxonomy Name | Lactation Consultant (Non-RN)
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License Number | ALPP-203587
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License Number State | CT
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