Healthcare Provider Details

I. General information

NPI: 1457960486
Provider Name (Legal Business Name): JILLIAN FOWLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JILLIAN SCOTT

II. Dates (important events)

Enumeration Date: 07/27/2020
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

282 WASHINGTON ST
HARTFORD CT
06106-3322
US

IV. Provider business mailing address

163 LOOMIS DR
WEST HARTFORD CT
06107-2012
US

V. Phone/Fax

Practice location:
  • Phone: 860-545-9200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number127269
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10820
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: