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General NPI Number Information
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NPI Number | 1174937114
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Entity Type | Individual
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Provider Name | JESSICA LYN CHAN APRN
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Gender | Female
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Dates
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Enumeration Date | 06/18/2014
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Last Update Date | 09/10/2018
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Provider Practice Location Address
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Address Line | 74 GROVE ST
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City | NEW LONDON
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State | CT
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Zip | 06320-6515
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Country | US
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Telephone | 860-447-6070
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Fax | 860-443-6616
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Provider Business Mailing Address
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Address Line | 999 FOXON ROAD SUITE 36
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City | NORTH BRANFORD
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State | CT
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Zip | 06471
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Country | US
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Telephone | 203-484-7334
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Fax | 203-484-7301
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0200X
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Taxonomy Name | Pediatric Nurse Practitioner
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License Number | 5804
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 163WP0200X
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Taxonomy Name | Pediatric Registered Nurse
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License Number | 94495
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License Number State | CT
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