Provider Demographics
NPI:1225221724
Name:IACAMPO, JENNIFER (PT)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:IACAMPO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:E
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:150 MANSFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-2026
Mailing Address - Country:US
Mailing Address - Phone:860-456-2232
Mailing Address - Fax:860-456-2256
Practice Address - Street 1:150 MANSFIELD AVE
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2026
Practice Address - Country:US
Practice Address - Phone:860-456-2232
Practice Address - Fax:860-456-2256
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT008171225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT080008171OtherANTHEM BC
CT004271003Medicaid
CT080008171OtherANTHEM BC