Provider Demographics
NPI:1689723223
Name:PECK, JODI LYNN (LCSW)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:LYNN
Last Name:PECK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:JODI
Other - Middle Name:L
Other - Last Name:SERRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:P. O. BOX 415933
Mailing Address - Street 2:HARTFORD HOSPITAL PROFESSIONAL SERVICES
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5933
Mailing Address - Country:US
Mailing Address - Phone:860-545-7602
Mailing Address - Fax:
Practice Address - Street 1:280 SOUTH MAIN STREET
Practice Address - Street 2:SUITE 102
Practice Address - City:CHESHIRE
Practice Address - State:CT
Practice Address - Zip Code:06410
Practice Address - Country:US
Practice Address - Phone:860-870-6385
Practice Address - Fax:203-250-0191
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0066081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004040614Medicaid