Healthcare Provider Details

I. General information

NPI: 1427453596
Provider Name (Legal Business Name): JENNA LEE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2014
Last Update Date: 06/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 PARK ST
NEW HAVEN CT
06511-5474
US

IV. Provider business mailing address

55 PARK ST
NEW HAVEN CT
06511-5474
US

V. Phone/Fax

Practice location:
  • Phone: 337-396-6425
  • Fax:
Mailing address:
  • Phone: 337-396-6425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License NumberPCT.0014479
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: