Provider Demographics
NPI:1194859884
Name:FOOTMAN, JACQUELINE (MSW)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:FOOTMAN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 CONSTITUTION ST
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-3824
Mailing Address - Country:US
Mailing Address - Phone:203-269-6728
Mailing Address - Fax:
Practice Address - Street 1:180 FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06604-4252
Practice Address - Country:US
Practice Address - Phone:203-394-6529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker