MEDICARE: MRS. JILL LESLIE DUBOFF-JACOMINI APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	000800	CT

General Provider Information

NPI Number	:	1538142435
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JILL LESLIE DUBOFF-JACOMINI APRN

Provider Business Mailing Address
First Line	:	263 FARMINGTON AVE
Second Line	:	PROVIDER ENROLLMENT
City	:	FARMINGTON
State	:	CT
Zip	:	06030-2212
Country	:	US
Telephone Number	:	860-679-7503
Fax Number	:	860-679-1610

Provider Business Practice Location Address
First Line	:	10 TALCOTT NOTCH RD
Second Line	:
City	:	FARMINGTON
State	:	CT
Zip	:	06032-1800
Country	:	US
Telephone Number	:	860-679-6700
Fax Number	:	860-679-6736

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/23/2005
Last Update Date	:	05/01/2013

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