Provider Demographics
NPI:1871330720
Name:GARY, JAELYNE DENECE
Entity type:Individual
Prefix:
First Name:JAELYNE
Middle Name:DENECE
Last Name:GARY
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 1:357 BRITTANY FARMS RD APT 124
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06053-1103
Mailing Address - Country:US
Mailing Address - Phone:239-265-0569
Mailing Address - Fax:
Practice Address - Street 1:91 NORTHWEST DR
Practice Address - Street 2:
Practice Address - City:PLAINVILLE
Practice Address - State:CT
Practice Address - Zip Code:06062-1534
Practice Address - Country:US
Practice Address - Phone:888-793-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTC062024001519103TS0200X
CT7444101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool