Provider Demographics
NPI:1366798118
Name:JESSICA R FAY LCSW LLC
Entity type:Organization
Organization Name:JESSICA R FAY LCSW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:R
Authorized Official - Last Name:FAY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:203-506-0789
Mailing Address - Street 1:14 TRUMBULL ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-6312
Mailing Address - Country:US
Mailing Address - Phone:203-506-0789
Mailing Address - Fax:
Practice Address - Street 1:14 TRUMBULL ST
Practice Address - Street 2:SUITE 102
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-6312
Practice Address - Country:US
Practice Address - Phone:203-506-0789
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-31
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006907251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health