Provider Demographics
NPI:1558364653
Name:COLUCCI, JENNIFER A (APRN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:COLUCCI
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 1:21 GRAND ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-1541
Mailing Address - Country:US
Mailing Address - Phone:860-550-7500
Mailing Address - Fax:860-550-7529
Practice Address - Street 1:21 GRAND ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-1541
Practice Address - Country:US
Practice Address - Phone:860-550-7500
Practice Address - Fax:860-550-7529
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002805363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004243630Medicaid
CT500001275Medicare ID - Type Unspecified
CTP98213Medicare UPIN