Provider Demographics
NPI:1205212172
Name:JENNIFER ROOT, LLC
Entity Type:Organization
Organization Name:JENNIFER ROOT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:ROOT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:860-993-7311
Mailing Address - Street 1:4074 MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:WEST SUFFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06093-2118
Mailing Address - Country:US
Mailing Address - Phone:860-993-7311
Mailing Address - Fax:
Practice Address - Street 1:139 HAZARD AVE
Practice Address - Street 2:BUILDING 2/UNIT 8
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-4585
Practice Address - Country:US
Practice Address - Phone:860-933-7311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-03
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT008779251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health