Provider Demographics
NPI:1891102299
Name:ROSENBAUM, JILL (PHD)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:
Last Name:ROSENBAUM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:ROSENBAUM
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:1 BLACHLEY RD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902
Mailing Address - Country:US
Mailing Address - Phone:203-276-8479
Mailing Address - Fax:203-276-2282
Practice Address - Street 1:1 BLACHLEY RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902
Practice Address - Country:US
Practice Address - Phone:203-276-8479
Practice Address - Fax:203-276-2282
Is Sole Proprietor?:No
Enumeration Date:2014-07-17
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021612103T00000X
103T00000X
CT003589103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist