MEDICARE: JESSICA LEVINNIA DIMOCK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	11145	CT

General Provider Information

NPI Number	:	1184143513
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA LEVINNIA DIMOCK

Provider Business Mailing Address
First Line	:	125 SOUTH ST APT 380
Second Line	:
City	:	VERNON
State	:	CT
Zip	:	06066-4470
Country	:	US
Telephone Number	:	860-455-3858
Fax Number	:

Provider Business Practice Location Address
First Line	:	1212 BOSTON TPKE STE B
Second Line	:
City	:	BOLTON
State	:	CT
Zip	:	06043-7451
Country	:	US
Telephone Number	:	860-782-0036
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/18/2017
Last Update Date	:	10/11/2024

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