Provider Demographics
NPI:1689787822
Name:COHEN, JAYNE (PHD)
Entity Type:Individual
Prefix:
First Name:JAYNE
Middle Name:
Last Name:COHEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 TUMBLEBROOK DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-2283
Mailing Address - Country:US
Mailing Address - Phone:860-644-3615
Mailing Address - Fax:
Practice Address - Street 1:933 HARTFORD TPKE
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-4407
Practice Address - Country:US
Practice Address - Phone:860-872-7696
Practice Address - Fax:860-871-0252
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001258103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTP557706OtherOXFORD PROVIER NUMBER
CT060001258CT02OtherBLUE SHILD PROVIDER NUMBE