Provider Demographics
NPI:1588784375
Name:BRISCOE, JAN FITZGERALD
Entity type:Individual
Prefix:MRS
First Name:JAN
Middle Name:FITZGERALD
Last Name:BRISCOE
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 1:322 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-2350
Mailing Address - Country:US
Mailing Address - Phone:860-395-3190
Mailing Address - Fax:860-395-3189
Practice Address - Street 1:81 HALLS RD UNIT C
Practice Address - Street 2:
Practice Address - City:OLD LYME
Practice Address - State:CT
Practice Address - Zip Code:06371
Practice Address - Country:US
Practice Address - Phone:860-304-9865
Practice Address - Fax:860-395-3189
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000884106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist