Provider Demographics
NPI:1073692950
Name:THOMPSON, JENNIFER L
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 QUEEN ST
Mailing Address - Street 2:STE 3
Mailing Address - City:NEWTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06470-2173
Mailing Address - Country:US
Mailing Address - Phone:203-232-7711
Mailing Address - Fax:203-263-7309
Practice Address - Street 1:12 QUEEN ST
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:CT
Practice Address - Zip Code:06470-2158
Practice Address - Country:US
Practice Address - Phone:203-232-7711
Practice Address - Fax:833-596-1603
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0047631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
800002661Medicare ID - Type Unspecified