=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134223654
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER P SWENSON M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2006
-----------------------------------------------------
Last Update Date | 01/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1291 BOSTON POST RD STE 105
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06443-3476
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-358-5100
-----------------------------------------------------
Fax | 860-358-8655
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28 CRESCENT ST
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06457-3654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-358-6000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 037842
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------