=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730784216
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AIMEE JETTE LPC, ATR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2020
-----------------------------------------------------
Last Update Date | 12/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 680 MAIN ST STE 305
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06795-2656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-293-8103
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 62 HIGH RIDGE AVE
-----------------------------------------------------
City | RIDGEFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06877-4913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-826-8983
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 4678
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------