Provider Demographics
NPI:1932185097
Name:GESINO, JACK P (LCSW)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:P
Last Name:GESINO
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:193 OLD COACH HWY
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-2024
Mailing Address - Country:US
Mailing Address - Phone:203-248-5787
Mailing Address - Fax:
Practice Address - Street 1:295 WASHINGTON AVE
Practice Address - Street 2:SUITE 5N
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3025
Practice Address - Country:US
Practice Address - Phone:203-248-5787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0018511041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001145368Medicaid
CT800002301Medicare ID - Type Unspecified
CT001145368Medicaid