Provider Demographics
NPI:1932396587
Name:BLANCHETTE, JAYNE WILSON
Entity Type:Individual
Prefix:MS
First Name:JAYNE
Middle Name:WILSON
Last Name:BLANCHETTE
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 1:540 HOPMEADOW ST
Mailing Address - Street 2:
Mailing Address - City:SIMSBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06070-2496
Mailing Address - Country:US
Mailing Address - Phone:860-558-8479
Mailing Address - Fax:
Practice Address - Street 1:540 HOPMEADOW ST
Practice Address - Street 2:
Practice Address - City:SIMSBURY
Practice Address - State:CT
Practice Address - Zip Code:06070-2496
Practice Address - Country:US
Practice Address - Phone:860-558-8479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-27
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002663104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT800001312Medicare PIN