Provider Demographics
NPI:1326388257
Name:AMBROISE, JEFFREY (LPC)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:
Last Name:AMBROISE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1268 MAIN ST STE 106
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-3043
Mailing Address - Country:US
Mailing Address - Phone:203-952-1900
Mailing Address - Fax:860-785-8925
Practice Address - Street 1:1268 MAIN ST STE 106
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-3043
Practice Address - Country:US
Practice Address - Phone:203-952-1900
Practice Address - Fax:860-785-8925
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-01
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002893101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional