Provider Demographics
NPI:1174627236
Name:JENCKS, PRISCILLA (LNM)
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:
Last Name:JENCKS
Suffix:
Gender:F
Credentials:LNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 INGRAM STREET
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06517
Mailing Address - Country:US
Mailing Address - Phone:203-287-9706
Mailing Address - Fax:
Practice Address - Street 1:374 GRAND AVE
Practice Address - Street 2:FAIR HAVEN COMMUNITY HEALTH CTR
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06513
Practice Address - Country:US
Practice Address - Phone:203-777-7411
Practice Address - Fax:203-777-8604
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000071367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000254189301OtherUNITED HEALTHCARE
0000719734OtherCT CARE
P3597631OtherOXFORD
400000071CT01OtherANTHEM BCBS