Basic Information
Provider Information
NPI: 1003000449
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: EVANS
FirstName: JACLYN
MiddleName: ANN
NamePrefix:  
NameSuffix:  
Credential: PSY.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
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OtherMiddleName:  
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OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 658
Address2: 435 EAST MAIN STREET
City: ANSONIA
State: CT
PostalCode: 064010658
CountryCode: US
TelephoneNumber: 2037362905
FaxNumber:  
Practice Location
Address1: 435 E MAIN ST
Address2:  
City: ANSONIA
State: CT
PostalCode: 064011964
CountryCode: US
TelephoneNumber: 2037362905
FaxNumber:  
Other Information
ProviderEnumerationDate: 08/29/2007
LastUpdateDate: 09/17/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YA0400X  N Behavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
101YM0800X  Y Behavioral Health & Social Service ProvidersCounselorMental Health

No ID Information.


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