Basic Information
| Provider Information | |||||||||
| NPI: | 1194070086 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORNING | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MSW,BA,LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 141 E MAIN ST | ||||||||
| Address2: | 4TH FLOOR ADMINISTRATION | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067022310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035749000 | ||||||||
| FaxNumber: | 2035749006 | ||||||||
| Practice Location | |||||||||
| Address1: | 141 E MAIN ST | ||||||||
| Address2: | WATERBURY CLINICAL SERVICES 2ND FLOOR | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067022310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037567287 | ||||||||
| FaxNumber: | 2035960722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2012 | ||||||||
| LastUpdateDate: | 08/25/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 1934 | CT | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 060669107 | 01 | CT | HEALTHYCT WELLMORE GRP/FACILITY | OTHER | PENDING | 01 | CT | AETNA BEHAVIORAL HEALTH | OTHER | PENDING | 01 | CT | CIGNA BEHAVIORAL HEALTH | OTHER | 060669107 | 01 | CT | ANTHEM BCBS OF CT BEHAVIORAL HEALTH-WELLMORE GRP/FACILITY | OTHER | 060669107 | 01 | CT | UBH/UNITED HEALTH CARE WELLMORE GRP/FACILITY | OTHER | 060669107 | 01 | CT | UNITED BEHAVIORAL HEALTH | OTHER | 060669107 | 01 | CT | UBH/OXFORD FREEDOM/OXFORD LIBERTY WELLMORE GRP/FACILITY060669107 | OTHER | NOT ELIGIBLE | 01 | CT | MHN MANAGED HEALTH NETWORK | OTHER | D339209 WATERBURY | 01 | CT | BEACON HEALTH STRATEGIES WELLMORE GRP/FACILITY | OTHER | 008060097 | 05 | CT | MEDICAID | 060669107 | 01 | CT | UBH/CONNECTICARE WELLMORE GRP/FACILITY | OTHER | 13605884 | 01 | CT | CAQH | OTHER | NOT ELIGIBLE | 01 | CT | MHN TRICARE NORTH | OTHER |