Provider Demographics
NPI:1952454993
Name:MCMAHON, JENNIFER L (LICSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:MCMAHON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:KLYBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:635 MAIN ST
Mailing Address - Street 2:ATTN: CREDENTIALING DPT
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-2718
Mailing Address - Country:US
Mailing Address - Phone:860-347-6971
Mailing Address - Fax:860-638-6601
Practice Address - Street 1:635 MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-2718
Practice Address - Country:US
Practice Address - Phone:860-347-6971
Practice Address - Fax:860-704-8034
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW01628104100000X
CT007533104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT00426338Medicaid