Provider Demographics
NPI:1144064643
Name:MAILS, JEANETTE ELLEN (LCAC)
Entity type:Individual
Prefix:
First Name:JEANETTE
Middle Name:ELLEN
Last Name:MAILS
Suffix:
Gender:F
Credentials:LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 THORPE AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-1948
Mailing Address - Country:US
Mailing Address - Phone:203-779-5799
Mailing Address - Fax:
Practice Address - Street 1:35 THORPE AVE
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-1999
Practice Address - Country:US
Practice Address - Phone:203-779-5799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87001705A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)