Provider Demographics
NPI:1538521927
Name:RUSSO-BOUDINOT, JACQUELYNN (LMFT, NCC, CDM)
Entity type:Individual
Prefix:
First Name:JACQUELYNN
Middle Name:
Last Name:RUSSO-BOUDINOT
Suffix:
Gender:F
Credentials:LMFT, NCC, CDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 MAIN ST STE 103A
Mailing Address - Street 2:
Mailing Address - City:CENTERBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06409-1057
Mailing Address - Country:US
Mailing Address - Phone:860-510-6130
Mailing Address - Fax:860-760-6706
Practice Address - Street 1:90 MAIN ST STE 103A
Practice Address - Street 2:
Practice Address - City:CENTERBROOK
Practice Address - State:CT
Practice Address - Zip Code:06409-1057
Practice Address - Country:US
Practice Address - Phone:860-510-6130
Practice Address - Fax:860-760-6706
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-24
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101YP2500X, 106H00000X
CT1806106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional