Provider Demographics
NPI:1518362995
Name:SHULL, JENNINE JO
Entity Type:Individual
Prefix:
First Name:JENNINE
Middle Name:JO
Last Name:SHULL
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 1:4 LIBERTY ST
Mailing Address - Street 2:APT. 3A
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-6782
Mailing Address - Country:US
Mailing Address - Phone:914-373-9535
Mailing Address - Fax:
Practice Address - Street 1:4 LIBERTY ST
Practice Address - Street 2:APT. 3A
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-6782
Practice Address - Country:US
Practice Address - Phone:914-373-9535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-28
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical