1538618269 NPI number — DR. JENNIFER JO BROUT PSY.D, ED.M

Table of content: DR. JENNIFER JO BROUT PSY.D, ED.M (NPI 1538618269)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538618269 NPI number — DR. JENNIFER JO BROUT PSY.D, ED.M

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROUT
Provider First Name:
JENNIFER
Provider Middle Name:
JO
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY.D, ED.M
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:
1538618269
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
231 WEAVER ST
Provider Second Line Business Mailing Address:
APT 16H
Provider Business Mailing Address City Name:
GREENWICH
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06831-4251
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
231 WEAVER ST
Provider Second Line Business Practice Location Address:
APT 16H
Provider Business Practice Location Address City Name:
GREENWICH
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06831-4251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
914-255-3839
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/22/2016

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: 101YP2500X , with the licence number:  002889 , 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)





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