Provider Demographics
NPI:1033972500
Name:STEVENS, JACQUELINE IVANA (LMSW)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:IVANA
Last Name:STEVENS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:954 BIRMINGHAM ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-3203
Mailing Address - Country:US
Mailing Address - Phone:203-682-5278
Mailing Address - Fax:
Practice Address - Street 1:954 BIRMINGHAM ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-3203
Practice Address - Country:US
Practice Address - Phone:203-682-5278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6921104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker