Healthcare Provider Details

I. General information

NPI: 1417414905
Provider Name (Legal Business Name): JESSICA KIBACK APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2019
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 RETREAT AVE STE 201
HARTFORD CT
06106-2528
US

IV. Provider business mailing address

100 RETREAT AVE STE 201
HARTFORD CT
06106-2528
US

V. Phone/Fax

Practice location:
  • Phone: 860-246-8568
  • Fax: 860-493-7798
Mailing address:
  • Phone: 860-246-8568
  • Fax: 860-493-7798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number12.008136
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number8136
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: