Healthcare Provider Details

I. General information

NPI: 1588028153
Provider Name (Legal Business Name): JENNIE THOMAS STANFORD M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2016
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

69 GROVE ST
NEW CANAAN CT
06840-5325
US

IV. Provider business mailing address

69 GROVE ST
NEW CANAAN CT
06840-5325
US

V. Phone/Fax

Practice location:
  • Phone: 844-359-8363
  • Fax: 833-929-3520
Mailing address:
  • Phone: 844-359-8363
  • Fax: 833-929-3520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number26586
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number1992372403
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number1992372403
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number1043889967
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: