Basic Information
| Provider Information | |||||||||
| NPI: | 1811005614 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAROSA | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRC, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14 CEDAR ST. | ||||||||
| Address2: | |||||||||
| City: | NEW BRITAIN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602129534 | ||||||||
| FaxNumber: | 8606120087 | ||||||||
| Practice Location | |||||||||
| Address1: | 14 CEDAR ST. | ||||||||
| Address2: | |||||||||
| City: | NEW BRITAIN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602129534 | ||||||||
| FaxNumber: | 8606120087 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 04/16/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 001382 | CT | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 004052015 | 05 | CT | MEDICAID |