Provider Demographics
NPI:1649392358
Name:MOTT, JACQUELINE L (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:L
Last Name:MOTT
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 131
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:CT
Mailing Address - Zip Code:06019-0131
Mailing Address - Country:US
Mailing Address - Phone:860-707-5009
Mailing Address - Fax:
Practice Address - Street 1:111 MAIN ST STE 2N
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:CT
Practice Address - Zip Code:06019-3182
Practice Address - Country:US
Practice Address - Phone:860-707-5009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001221106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist