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General NPI Number Information
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NPI Number | 1740544709
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Entity Type | Individual
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Provider Name | MARISSA JACKO MPAS, PA-C
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Gender | Female
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Dates
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Enumeration Date | 06/25/2012
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Last Update Date | 08/30/2021
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Provider Practice Location Address
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Address Line | 20 YORK ST
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City | NEW HAVEN
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State | CT
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Zip | 06510-3220
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Country | US
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Telephone | 203-688-3335
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Fax | 203-688-3336
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Provider Business Mailing Address
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Address Line | 20 YORK ST SICU 7 SOUTH PAVILION, ROOM 7-109
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City | NEW HAVEN
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State | CT
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Zip | 06510-3220
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Country | US
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Telephone | 203-688-3335
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Fax | 203-688-3336
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 002773
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License Number State | CT
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