1508974288 NPI number — DR. JENNIFER ANNE ANDRADE PSY.D.

Table of content: DR. JENNIFER ANNE ANDRADE PSY.D. (NPI 1508974288)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508974288 NPI number — DR. JENNIFER ANNE ANDRADE PSY.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDRADE
Provider First Name:
JENNIFER
Provider Middle Name:
ANNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508974288
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24 TUNXIS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWINGTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06111-3441
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-436-2036
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
80 GARDEN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WETHERSFIELD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06109-3120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-836-5490
Provider Business Practice Location Address Fax Number:
860-529-7820
Provider Enumeration Date:
08/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  002634 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0060002634CT01 . This is a "ANTHEM BLUE CROSS BLUE SH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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