Provider Demographics
NPI:1649587924
Name:DECOSMO, JENNIFER LYNE (LPC)
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:LYNE
Last Name:DECOSMO
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-2281
Mailing Address - Country:US
Mailing Address - Phone:203-575-0466
Mailing Address - Fax:203-575-1817
Practice Address - Street 1:380 MAIN ST
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-2281
Practice Address - Country:US
Practice Address - Phone:203-575-0466
Practice Address - Fax:203-575-1817
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-08
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001917101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT08037449Medicaid