Provider Demographics
NPI:1407463235
Name:CORDEIRO, JENNA KAITLYN (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:KAITLYN
Last Name:CORDEIRO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 MILL PLAIN RD UNIT B
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-2710
Mailing Address - Country:US
Mailing Address - Phone:860-682-0851
Mailing Address - Fax:
Practice Address - Street 1:154 MAIN ST
Practice Address - Street 2:
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-2373
Practice Address - Country:US
Practice Address - Phone:860-358-4130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-25
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4968363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant