Provider Demographics
NPI:1902077878
Name:BLAKESLEE, JENNIFER A (LCSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:BLAKESLEE
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 1:28 CRESCENT ST
Mailing Address - Street 2:MIDDLESEX HOSPITAL FAMILY ADVOCACY
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457
Mailing Address - Country:US
Mailing Address - Phone:860-358-3401
Mailing Address - Fax:860-358-3403
Practice Address - Street 1:28 CRESCENT ST
Practice Address - Street 2:MIDDLESEX HOSPITAL FAMILY ADVOCACY
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457
Practice Address - Country:US
Practice Address - Phone:860-358-3401
Practice Address - Fax:860-358-3403
Is Sole Proprietor?:No
Enumeration Date:2008-03-18
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0066111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT006611OtherLCSW LIC #