Provider Demographics
NPI:1194038174
Name:GAGNON, JESSICA M (LCSW)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:M
Last Name:GAGNON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 LONG HILL RD # 201
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-3811
Mailing Address - Country:US
Mailing Address - Phone:860-800-2107
Mailing Address - Fax:860-450-1357
Practice Address - Street 1:428 LONG HILL RD STE 201
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340
Practice Address - Country:US
Practice Address - Phone:860-705-2840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-20
Last Update Date:2018-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004040564Medicaid