Provider Demographics
NPI:1205642790
Name:POULARD, JEAN-LUC (LMSW)
Entity type:Individual
Prefix:
First Name:JEAN-LUC
Middle Name:
Last Name:POULARD
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 LEDGEBROOK DR STE C
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD CENTER
Mailing Address - State:CT
Mailing Address - Zip Code:06250-1644
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6 LEDGEBROOK DR
Practice Address - Street 2:C
Practice Address - City:MANSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06250
Practice Address - Country:US
Practice Address - Phone:860-833-2657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7743104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker