Provider Demographics
NPI:1326349820
Name:AMMERMAN, JESSYCA LYN (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSYCA
Middle Name:LYN
Last Name:AMMERMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JESSYCA
Other - Middle Name:LYN
Other - Last Name:KNEEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2928 MAIN STREET
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033
Mailing Address - Country:US
Mailing Address - Phone:860-430-1246
Mailing Address - Fax:203-905-6824
Practice Address - Street 1:2165 DIXWELL AVE
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06514-2116
Practice Address - Country:US
Practice Address - Phone:203-248-2727
Practice Address - Fax:203-691-9673
Is Sole Proprietor?:No
Enumeration Date:2010-11-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002491363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant