Provider Demographics
NPI:1114743424
Name:FARGEORGE, JIRINA ANN (LMSW)
Entity type:Individual
Prefix:
First Name:JIRINA
Middle Name:ANN
Last Name:FARGEORGE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 CONNOLLY PKWY BLDG 2B
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06514-2593
Mailing Address - Country:US
Mailing Address - Phone:203-909-6705
Mailing Address - Fax:475-238-6355
Practice Address - Street 1:60 CONNOLLY PKWY BLDG 2B
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06514-2593
Practice Address - Country:US
Practice Address - Phone:203-909-6705
Practice Address - Fax:475-238-6355
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT10066101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT800424787Medicaid