MEDICARE: UNDER THE JEWEL TREE 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	106H00000X	Marriage & Family Therapist	001880	CT

General Provider Information

NPI Number	:	1851827760
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNDER THE JEWEL TREE LLC

Provider Business Mailing Address
First Line	:	11 TURNER LN
Second Line	:
City	:	WILTON
State	:	CT
Zip	:	06897-2009
Country	:	US
Telephone Number	:	203-489-3711
Fax Number	:

Provider Business Practice Location Address
First Line	:	79 E PUTNAM AVE
Second Line	:	STE. 14
City	:	GREENWICH
State	:	CT
Zip	:	06830-5644
Country	:	US
Telephone Number	:	203-489-3711
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	MACKENZIE JENNINGS
Credential	:
Telephone Number	:	617-454-4916

Provider Enumeration Date	:	05/11/2017
Last Update Date	:	05/11/2017

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Directions to “UNDER THE JEWEL TREE LLC ” Practice Location

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