Provider Demographics
NPI:1700149705
Name:PHUNG, JEANNE (LCSW)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:
Last Name:PHUNG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 CONTROLS DR
Mailing Address - Street 2:SUITE 10
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-6157
Mailing Address - Country:US
Mailing Address - Phone:203-525-8280
Mailing Address - Fax:866-394-4521
Practice Address - Street 1:30 CONTROLS DR
Practice Address - Street 2:SUITE 10
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-6157
Practice Address - Country:US
Practice Address - Phone:203-525-8280
Practice Address - Fax:866-394-4521
Is Sole Proprietor?:No
Enumeration Date:2012-06-25
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004025219Medicaid