Provider Demographics
NPI:1619076254
Name:POWERS, JOLYNN (PSYD)
Entity Type:Individual
Prefix:
First Name:JOLYNN
Middle Name:
Last Name:POWERS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:JOLYNN
Other - Middle Name:
Other - Last Name:FALLICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:PO BOX 174
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06250-0174
Mailing Address - Country:US
Mailing Address - Phone:860-456-4604
Mailing Address - Fax:860-456-1738
Practice Address - Street 1:207 STORRS RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06250-0174
Practice Address - Country:US
Practice Address - Phone:860-456-4604
Practice Address - Fax:860-456-1738
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001632103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004103305Medicaid
216555OtherUNITED BEH HEALTH
P421340OtherOXFORD
108475OtherVALUE OPTIONS
220926OtherMHN
C007612OtherTRICARE