Healthcare Provider Details

I. General information

NPI: 1386485167
Provider Name (Legal Business Name): AMANDA MARIE JACOBS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2024
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 PLEASANT ST
SOUTHINGTON CT
06489-2752
US

IV. Provider business mailing address

41 KINGWOOD PL
NEW BRITAIN CT
06053-1733
US

V. Phone/Fax

Practice location:
  • Phone: 860-628-3229
  • Fax: 860-628-3397
Mailing address:
  • Phone: 860-938-5602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2043
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: