Provider Demographics
NPI:1538579222
Name:MAYO, JESSICA (PHD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MAYO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 207900
Mailing Address - Street 2:230 SOUTH FRONTAGE ROAD
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06520
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:230 S FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1124
Practice Address - Country:US
Practice Address - Phone:209-785-7803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-02
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003576103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent