Individual
MARY CASEY JACOB
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PH.D.
Contact information
Practice address
263 FARMINGTON AVE, FARMINGTON, CT 06030-0001
(860) 679-4550
(860) 679-1845
Mailing address
263 FARMINGTON AVE, PROVIDER ENROLLMENT, FARMINGTON, CT 06030-2212
(860) 679-7503
(860) 679-1610
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
001621
CT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1083612246
—
CT
Enumeration date
07/12/2005
Last updated
02/19/2014
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