Healthcare Provider Details

I. General information

NPI: 1679646921
Provider Name (Legal Business Name): JESSICA K HANSEN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 08/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 WESTBROOK RD
ESSEX CT
06426-1512
US

IV. Provider business mailing address

28 CRESCENT ST
MIDDLETOWN CT
06457-3654
US

V. Phone/Fax

Practice location:
  • Phone: 860-767-8265
  • Fax: 860-358-8653
Mailing address:
  • Phone: 860-358-4820
  • Fax: 860-358-6748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001158
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: