Provider Demographics
NPI:1538142435
Name:DUBOFF-JACOMINI, JILL LESLIE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:LESLIE
Last Name:DUBOFF-JACOMINI
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:263 FARMINGTON AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-2212
Mailing Address - Country:US
Mailing Address - Phone:860-679-7503
Mailing Address - Fax:860-679-1610
Practice Address - Street 1:10 TALCOTT NOTCH RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1800
Practice Address - Country:US
Practice Address - Phone:860-679-6700
Practice Address - Fax:860-679-6736
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000800363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTS94067Medicare UPIN