Basic Information
| Provider Information | |||||||||
| NPI: | 1871003343 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 LONG WHARF DR STE 321 | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065115946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037814600 | ||||||||
| FaxNumber: | 2037814624 | ||||||||
| Practice Location | |||||||||
| Address1: | 54 E RAMSDELL ST | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065151140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037814600 | ||||||||
| FaxNumber: | 2037814624 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2017 | ||||||||
| LastUpdateDate: | 08/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 3616 | CT | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 11082 | CT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 008039745 | 05 | CT | MEDICAID | 008023170 | 05 | CT | MEDICAID | 3616 | 01 | CT | STATE OF CT DPH | OTHER | 008096553 | 05 | CT | MEDICAID | 008024427 | 05 | CT | MEDICAID | 008042339 | 05 | CT | MEDICAID |