Provider Demographics
NPI:1467022830
Name:JACQUES, CARLY RAE (LCSW)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:RAE
Last Name:JACQUES
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 1:75 WEST ST
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-6528
Mailing Address - Country:US
Mailing Address - Phone:860-354-8556
Mailing Address - Fax:860-354-3975
Practice Address - Street 1:325 DANBURY RD
Practice Address - Street 2:
Practice Address - City:NEW MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06776-4344
Practice Address - Country:US
Practice Address - Phone:860-354-8556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTMSW.005035104100000X
CT0121821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker