Provider Demographics
NPI:1124483771
Name:SMITH, JANE DANETTE
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:DANETTE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:DANETTE
Other - Last Name:PERTILLAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:135 HARTLAND ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06112-1131
Mailing Address - Country:US
Mailing Address - Phone:860-670-0955
Mailing Address - Fax:
Practice Address - Street 1:15 MULBERRY STREET
Practice Address - Street 2:PHOENIX HOUSE
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01105
Practice Address - Country:US
Practice Address - Phone:413-739-1087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-28
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor