Provider Demographics
NPI:1417414905
Name:KIBACK, JESSICA (APRN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:KIBACK
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 1:100 RETREAT AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-2528
Mailing Address - Country:US
Mailing Address - Phone:860-246-8568
Mailing Address - Fax:860-493-7798
Practice Address - Street 1:100 RETREAT AVE STE 201
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-2528
Practice Address - Country:US
Practice Address - Phone:860-246-8568
Practice Address - Fax:860-493-7798
Is Sole Proprietor?:No
Enumeration Date:2019-02-21
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8136363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health