Healthcare Provider Details

I. General information

NPI: 1790148914
Provider Name (Legal Business Name): JESSICA FENNELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2016
Last Update Date: 12/24/2024
Certification Date: 12/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

282 WASHINGTON ST
HARTFORD CT
06106-3322
US

IV. Provider business mailing address

535 E 70TH ST
NEW YORK NY
10021-4823
US

V. Phone/Fax

Practice location:
  • Phone: 860-545-9970
  • Fax:
Mailing address:
  • Phone: 917-260-3909
  • Fax: 917-260-4522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number70529
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number107775809
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code2080P0216X
TaxonomyPediatric Rheumatology Physician
License Number70529
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: