Provider Demographics
NPI:1316001647
Name:CHAMPAGNE, JENNIFER LUISE (MA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LUISE
Last Name:CHAMPAGNE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 WHIPPORWILL DR
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-5900
Mailing Address - Country:US
Mailing Address - Phone:203-925-1428
Mailing Address - Fax:
Practice Address - Street 1:435 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ANSONIA
Practice Address - State:CT
Practice Address - Zip Code:06401-1964
Practice Address - Country:US
Practice Address - Phone:203-736-2601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000095101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional