Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor | 3158 | CT |
N | 174N00000X | Lactation Consultant | ALPP-203587 | CT |
NPI | 1093115974 |
---|---|
Provider Name | Jackie Small |
First Address | Westport, CT 06880-5525 |
Second Address | Westport, CT 06880-5525 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/08/2014 |
Last Update Date | 31/03/2017 |