Provider Demographics
NPI:1265456347
Name:JACK, KATHRYN E (APRN)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:E
Last Name:JACK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2139 SILAS DEANE HWY
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067-2336
Mailing Address - Country:US
Mailing Address - Phone:860-257-4131
Mailing Address - Fax:860-257-4519
Practice Address - Street 1:455 LEWIS AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06451-2121
Practice Address - Country:US
Practice Address - Phone:203-886-0036
Practice Address - Fax:203-886-0072
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002455363L00000X, 363LA2200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004219491Medicaid
CTP47490Medicare UPIN
CT500000762Medicare PIN
CT004219491Medicaid