Basic Information
| Provider Information | |||||||||
| NPI: | 1194247916 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MADDERN | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1558 BARNUM AVENUE | ||||||||
| Address2: | BUILDING C | ||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033843377 | ||||||||
| FaxNumber: | 2033788578 | ||||||||
| Practice Location | |||||||||
| Address1: | 1558 BARNUM AVENUE | ||||||||
| Address2: | BUILDING C | ||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033843377 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2017 | ||||||||
| LastUpdateDate: | 07/13/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | 008033 | CT | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 1041C0700X | 008033 | CT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 2084P0800X | 008033 | CT | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.