Provider Demographics
NPI:1902179690
Name:PAGE, JESSICA R (LADC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:R
Last Name:PAGE
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 PENFIELD RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-6611
Mailing Address - Country:US
Mailing Address - Phone:203-255-5777
Mailing Address - Fax:203-368-9167
Practice Address - Street 1:125 PENFIELD RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-6611
Practice Address - Country:US
Practice Address - Phone:203-255-5777
Practice Address - Fax:203-368-9167
Is Sole Proprietor?:No
Enumeration Date:2012-02-11
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001292101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004069985Medicaid