MEDICARE: JESSICA R FAY LCSW LLC

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	251S00000X	Community/Behavioral Health Agency	006907	CT

General Provider Information

NPI Number	:	1366798118
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JESSICA R FAY LCSW LLC

Provider Business Mailing Address
First Line	:	14 TRUMBULL ST
Second Line	:	SUITE 102
City	:	NEW HAVEN
State	:	CT
Zip	:	06511-6312
Country	:	US
Telephone Number	:	203-506-0789
Fax Number	:

Provider Business Practice Location Address
First Line	:	14 TRUMBULL ST
Second Line	:	SUITE 102
City	:	NEW HAVEN
State	:	CT
Zip	:	06511-6312
Country	:	US
Telephone Number	:	203-506-0789
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JESSICA R FAY
Credential	:	LCSW
Telephone Number	:	203-506-0789

Provider Enumeration Date	:	07/31/2012
Last Update Date	:	07/31/2012

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