Provider Demographics
NPI:1508974288
Name:ANDRADE, JENNIFER ANNE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ANNE
Last Name:ANDRADE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 TUNXIS RD
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-3441
Mailing Address - Country:US
Mailing Address - Phone:860-436-2036
Mailing Address - Fax:
Practice Address - Street 1:80 GARDEN ST
Practice Address - Street 2:
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109-3120
Practice Address - Country:US
Practice Address - Phone:860-836-5490
Practice Address - Fax:860-529-7820
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002634103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0060002634CT01OtherANTHEM BLUE CROSS BLUE SH