Provider Demographics
NPI:1215785894
Name:WALSH, JENNIFER ASHLEIGH
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ASHLEIGH
Last Name:WALSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 HEBRON AVE
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-2176
Mailing Address - Country:US
Mailing Address - Phone:860-202-0673
Mailing Address - Fax:
Practice Address - Street 1:300 HEBRON AVE
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-2176
Practice Address - Country:US
Practice Address - Phone:860-946-0447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-09
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8650104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker