Provider Demographics
NPI:1548369176
Name:FOX, JENNIFER M (PHD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:FOX
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:M
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 894
Mailing Address - Street 2:1066 STORRS RD
Mailing Address - City:STORRS
Mailing Address - State:CT
Mailing Address - Zip Code:06268-0894
Mailing Address - Country:US
Mailing Address - Phone:860-977-8290
Mailing Address - Fax:
Practice Address - Street 1:1066 STORRS RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD CENTER
Practice Address - State:CT
Practice Address - Zip Code:06268
Practice Address - Country:US
Practice Address - Phone:860-977-8290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002326103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
217951OtherUNITED BEH HEALTH
CT060002326CT01OtherANTHEM