Provider Demographics
NPI:1285011361
Name:JEANNIE DILWORTH, LLC
Entity type:Organization
Organization Name:JEANNIE DILWORTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIC NURSE PRACTITIONER/OWNE
Authorized Official - Prefix:
Authorized Official - First Name:JEANNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DILWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:860-335-6834
Mailing Address - Street 1:642 HILLIARD ST STE 1315
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-2700
Mailing Address - Country:US
Mailing Address - Phone:860-335-6834
Mailing Address - Fax:833-901-3911
Practice Address - Street 1:642 HILLIARD ST STE 1315
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042-2700
Practice Address - Country:US
Practice Address - Phone:860-335-7221
Practice Address - Fax:833-901-3911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-28
Last Update Date:2025-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001987363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008058819Medicaid