Provider Demographics
NPI:1487636346
Name:WALZ, JENNIFER LYNNE (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNNE
Last Name:WALZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 GEORGE ST
Mailing Address - Street 2:601
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-6624
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-785-4851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000918363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT2V9257OtherHEALTHNET
CT290000918CT07OtherANTHEM BCBS
CT090918OtherCONNECTICARE
CT970001979Medicare ID - Type Unspecified
CT290000918CT07OtherANTHEM BCBS
CT970002567Medicare PIN