Provider Demographics
NPI:1043593783
Name:JEWELL, JACINTA
Entity Type:Individual
Prefix:
First Name:JACINTA
Middle Name:
Last Name:JEWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 281
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:CT
Mailing Address - Zip Code:06350-0281
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:399 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-5414
Practice Address - Country:US
Practice Address - Phone:860-885-0389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0008580183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist