Provider Demographics
NPI:1245337435
Name:SULLIVAN, JACQUELINE A (MSW)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:A
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 HIGHLAND AVENUE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708
Mailing Address - Country:US
Mailing Address - Phone:203-755-9300
Mailing Address - Fax:203-754-3196
Practice Address - Street 1:417 HIGHLAND AVENUE
Practice Address - Street 2:SUITE 1
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708
Practice Address - Country:US
Practice Address - Phone:203-755-9300
Practice Address - Fax:203-754-3196
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0024881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT140002488CT03OtherANTHEM BLUE CROSS BLUE SH