Provider Demographics
NPI:1336591924
Name:CLEAVER, JEANNINE (LCSW)
Entity type:Individual
Prefix:
First Name:JEANNINE
Middle Name:
Last Name:CLEAVER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JEANNINE
Other - Middle Name:
Other - Last Name:GEMMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12 ROOSEVELT AVE # MAILBOX5
Mailing Address - Street 2:
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355-2809
Mailing Address - Country:US
Mailing Address - Phone:602-459-8408
Mailing Address - Fax:
Practice Address - Street 1:12 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-2809
Practice Address - Country:US
Practice Address - Phone:602-459-8408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CT103961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor