Provider Demographics
NPI:1508101395
Name:KING, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7B LEDGEBROOK DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD CENTER
Mailing Address - State:CT
Mailing Address - Zip Code:06250-1664
Mailing Address - Country:US
Mailing Address - Phone:860-456-0038
Mailing Address - Fax:860-456-8765
Practice Address - Street 1:7B LEDGEBROOK DR
Practice Address - Street 2:
Practice Address - City:MANSFIELD CENTER
Practice Address - State:CT
Practice Address - Zip Code:06250-1664
Practice Address - Country:US
Practice Address - Phone:860-456-0038
Practice Address - Fax:860-456-8765
Is Sole Proprietor?:No
Enumeration Date:2012-12-05
Last Update Date:2023-05-31
Deactivation Date:2022-07-19
Deactivation Code:
Reactivation Date:2023-05-31
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health