Basic Information
| Provider Information | |||||||||
| NPI: | 1487808143 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUMPHREY | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | CATHERINE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC, NBCC, MS,BA | ||||||||
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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: | WELLMORE INC-3RD FLOOR | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067022310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035750456 | ||||||||
| FaxNumber: | 2035751817 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2008 | ||||||||
| LastUpdateDate: | 05/11/2016 | ||||||||
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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 | 101YP2500X | 001348 | CT | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 008037434 | 05 | CT | MEDICAID | 4687873 | 01 | CT | CIGNA BEHAVIORAL HEALTH | OTHER | 060669107 | 01 | CT | UBH-CONNECTICARE WELLMORE GRP/FACILITY | OTHER | D339123 141 E MAIN | 01 | CT | BEACON HEALTH STRATEGIES | OTHER | 060669107 | 01 | CT | ANTHEM BCBS OF CT WELLMORE GRP/FACILITY | OTHER | 060669107 | 01 | CT | HEALTHYCT WELLMORE GRP/FACILITY | OTHER | 539524 | 01 | CT | MHN MANAGED HEALTHCARE | OTHER | 9403704 | 01 | CT | AETNA BEHAVIORAL HEALTH | OTHER | NBCC-62197 | 01 | CT | NATIONAL BOARD OF CERTIFIED COUNSELORS | OTHER | 060669107 | 01 | CT | OPTUM BEHAVIORAL HEALTH/UBH WELLMORE GRP/FACILITY | OTHER | 060669107 | 01 | CT | UBH-UNITED HEALTHCARE WELLMORE GRP/FACILITY | OTHER | 539524 PENDING | 01 | CT | MHN TRICARE NORTH | OTHER | 060669107 | 01 | CT | UBH- OXFORD FREEDOM/LIBERTY WELLMORE GRP/FACILITY | OTHER | 13540256 | 01 | CT | CAQH | OTHER |