Provider Demographics
NPI:1013095231
Name:TATTERSALL, JENNIFER ALICE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ALICE
Last Name:TATTERSALL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:ALICE
Other - Last Name:REEVES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:62 BROADWAY STE 1
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-5702
Mailing Address - Country:US
Mailing Address - Phone:860-639-6880
Mailing Address - Fax:
Practice Address - Street 1:62 BROADWAY STE 1
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-5702
Practice Address - Country:US
Practice Address - Phone:860-639-6880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0055821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004255396Medicaid