Basic Information
Provider Information | |||||||||
NPI: | 1689723223 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PECK | ||||||||
FirstName: | JODI | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SERRA | ||||||||
OtherFirstName: | JODI | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MSW | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | P. O. BOX 415933 | ||||||||
Address2: | HARTFORD HOSPITAL PROFESSIONAL SERVICES | ||||||||
City: | BOSTON | ||||||||
State: | MA | ||||||||
PostalCode: | 022415933 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8605457602 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 280 SOUTH MAIN STREET | ||||||||
Address2: | SUITE 102 | ||||||||
City: | CHESHIRE | ||||||||
State: | CT | ||||||||
PostalCode: | 06410 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8608706385 | ||||||||
FaxNumber: | 2032500191 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/10/2007 | ||||||||
LastUpdateDate: | 07/19/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/19/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 006608 | CT | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 004040614 | 05 | CT |   | MEDICAID |