Provider Demographics
NPI:1750301925
Name:BALLEW, JENNIFER R (DO, PHD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:R
Last Name:BALLEW
Suffix:
Gender:F
Credentials:DO, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1951
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05302-1951
Mailing Address - Country:US
Mailing Address - Phone:203-784-8700
Mailing Address - Fax:203-784-8703
Practice Address - Street 1:1450 CHAPEL STREET
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511
Practice Address - Country:US
Practice Address - Phone:203-784-8700
Practice Address - Fax:203-784-8703
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0426262084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400008881Medicare PIN