Provider Demographics
NPI:1386897122
Name:RESNICKOFF, JESSICA (LCSW)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:RESNICKOFF
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 1:150 N. MAIN ST., SUITE 130
Mailing Address - Street 2:ECHN MEDICAL BUILDING
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-2086
Mailing Address - Country:US
Mailing Address - Phone:860-533-3434
Mailing Address - Fax:860-647-6829
Practice Address - Street 1:71 HAYNES ST
Practice Address - Street 2:MANCHESTER MEMORIAL HOSPITAL
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4131
Practice Address - Country:US
Practice Address - Phone:860-533-3494
Practice Address - Fax:860-647-6831
Is Sole Proprietor?:No
Enumeration Date:2008-10-24
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0068861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT006886OtherCT LICENSE
CT004025177Medicaid
CTC00006Medicare PIN