Provider Demographics
NPI:1417329954
Name:BRANT, JENNIFER REBECCA (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:REBECCA
Last Name:BRANT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5002 DURHAM RD
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-3610
Mailing Address - Country:US
Mailing Address - Phone:203-804-5218
Mailing Address - Fax:
Practice Address - Street 1:147 DURHAM RD
Practice Address - Street 2:SUITE 1
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-2675
Practice Address - Country:US
Practice Address - Phone:203-804-5218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-23
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0090921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT009092OtherLCSW LIC #