Provider Demographics
NPI:1316107402
Name:TRUJILLO, JEANETTE B (PSYD)
Entity type:Individual
Prefix:DR
First Name:JEANETTE
Middle Name:B
Last Name:TRUJILLO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1177 HIGH RIDGE RD.
Mailing Address - Street 2:SUITE 240
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905
Mailing Address - Country:US
Mailing Address - Phone:203-912-2093
Mailing Address - Fax:
Practice Address - Street 1:1177 HIGH RIDGE RD.
Practice Address - Street 2:SUITE 240
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905
Practice Address - Country:US
Practice Address - Phone:203-912-2039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-11
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002867103T00000X, 103TC0700X
NY016860103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist