Provider Demographics
NPI:1609919810
Name:DRISCOLL, JEREMY
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:DRISCOLL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JEREMY
Other - Middle Name:
Other - Last Name:DRISCOLL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:150 SYCAMORE DR
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790-4262
Mailing Address - Country:US
Mailing Address - Phone:860-309-7034
Mailing Address - Fax:
Practice Address - Street 1:150 SYCAMORE DR
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-4262
Practice Address - Country:US
Practice Address - Phone:860-309-7034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0002091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical