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General NPI Number Information
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NPI Number | 1467022830
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Entity Type | Individual
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Provider Name | CARLY RAE JACQUES LCSW
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Gender | Female
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Dates
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Enumeration Date | 06/29/2021
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Last Update Date | 05/20/2022
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Provider Practice Location Address
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Address Line | 325 DANBURY RD
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City | NEW MILFORD
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State | CT
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Zip | 06776-4344
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Country | US
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Telephone | 860-354-8556
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Fax |
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Provider Business Mailing Address
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Address Line | 75 WEST ST
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City | DANBURY
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State | CT
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Zip | 06810-6528
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Country | US
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Telephone | 860-354-8556
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Fax | 860-354-3975
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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 | 104100000X
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Taxonomy Name | Social Worker
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License Number | MSW.005035
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 012182
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License Number State | CT
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