=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548917594
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REVIVE CENTER FOR HEALTH & WELLNESS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2022
-----------------------------------------------------
Last Update Date | 06/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 281 HARTFORD TPKE STE 106
-----------------------------------------------------
City | VERNON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06066-4760
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-375-2227
-----------------------------------------------------
Fax | 860-603-5080
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 281 HARTFORD TPKE STE 106
-----------------------------------------------------
City | VERNON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06066-4760
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-375-2227
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTITIONER
-----------------------------------------------------
Name | JENNIFER MARIA SOUSA JEROME
-----------------------------------------------------
Credential | MSN, APRN, FNP-BC
-----------------------------------------------------
Telephone | 860-375-2227
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------