Healthcare Provider Details

I. General information

NPI: 1205816311
Provider Name (Legal Business Name): JENNIFER L. RIVERS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 09/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 MAIN STREET HARTFORD CITY TOWN HALL
HARTFORD CT
06103
US

IV. Provider business mailing address

1000 ASYLUM AVENUE SUITE 2109A
HARTFORD CT
06105
US

V. Phone/Fax

Practice location:
  • Phone: 860-543-8602
  • Fax: 860-722-8041
Mailing address:
  • Phone: 860-714-5058
  • Fax: 860-714-8311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number238002
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number003530
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3530
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3530
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: