Provider Demographics
NPI:1073238119
Name:NETTLE, JEFFREY (MA, LPC)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:NETTLE
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 RED OAK CIR
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-3872
Mailing Address - Country:US
Mailing Address - Phone:203-577-8679
Mailing Address - Fax:
Practice Address - Street 1:107 CHURCH HILL RD
Practice Address - Street 2:
Practice Address - City:SANDY HOOK
Practice Address - State:CT
Practice Address - Zip Code:06482-1194
Practice Address - Country:US
Practice Address - Phone:474-323-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-11
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5855101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional