Provider Demographics
NPI:1184143513
Name:DIMOCK, JESSICA LEVINNIA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEVINNIA
Last Name:DIMOCK
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 1:125 SOUTH ST APT 380
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-4470
Mailing Address - Country:US
Mailing Address - Phone:860-455-3858
Mailing Address - Fax:
Practice Address - Street 1:1212 BOSTON TPKE STE B
Practice Address - Street 2:
Practice Address - City:BOLTON
Practice Address - State:CT
Practice Address - Zip Code:06043-7451
Practice Address - Country:US
Practice Address - Phone:860-782-0036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-18
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT111451041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical