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General NPI Number Information
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NPI Number | 1427496108
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Entity Type | Individual
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Provider Name | JENNIE SONG PSY.D.
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Gender | Female
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Dates
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Enumeration Date | 06/04/2013
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Last Update Date | 11/17/2023
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Provider Practice Location Address
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Address Line | 270 FARMINGTON AVE STE 313
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City | FARMINGTON
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State | CT
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Zip | 06032-1909
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Country | US
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Telephone | 860-333-8421
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Fax |
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Provider Business Mailing Address
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Address Line | 55 BRINLEY WAY
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City | NEWINGTON
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State | CT
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Zip | 06111-1152
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Country | US
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Telephone | 860-878-9333
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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 | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 004249
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License Number State | CT
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