Provider Demographics
NPI:1871269639
Name:FIDLER, JESSICA ANN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:FIDLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 BEDFORD ST APT 3P
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-5224
Mailing Address - Country:US
Mailing Address - Phone:609-439-5637
Mailing Address - Fax:
Practice Address - Street 1:55 STRAWBERRY HILL AVE
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-2608
Practice Address - Country:US
Practice Address - Phone:203-977-5489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4793101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health