Provider Demographics
NPI:1093115974
Name:SMALL, JACKIE (MA, LPC, CLC)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:SMALL
Suffix:
Gender:F
Credentials:MA, LPC, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 TURKEY HILL RD S
Mailing Address - Street 2:SUITE 2L
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-5525
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 TURKEY HILL RD S
Practice Address - Street 2:SUITE 2L
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-5525
Practice Address - Country:US
Practice Address - Phone:646-246-7379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-28
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3158101YP2500X
CTALPP-203587174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No174N00000XOther Service ProvidersLactation Consultant, Non-RN