=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710363874
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER ESPINOZA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2015
-----------------------------------------------------
Last Update Date | 07/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 642 HILLIARD ST
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06042-2701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-783-8852
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 47 CIDER BROOK DR
-----------------------------------------------------
City | WETHERSFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06109-3263
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-638-8518
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 4225
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------