Healthcare Provider Details

I. General information

NPI: 1124797808
Provider Name (Legal Business Name): JENNIFER EVANS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2021
Last Update Date: 09/20/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 KNIGHT ST STE 101
NORWALK CT
06851-4707
US

IV. Provider business mailing address

1290 SILAS DEANE HIGHWAY HHC - CVO
WETHERSFIELD CT
06109-4337
US

V. Phone/Fax

Practice location:
  • Phone: 203-845-2460
  • Fax: 203-663-7978
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5463
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: