Provider Demographics
NPI:1558402230
Name:DODGE, JENNIFER (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DODGE
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 1:40 TEMPLE ST
Mailing Address - Street 2:SUITE 4A
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-2715
Mailing Address - Country:US
Mailing Address - Phone:203-777-0304
Mailing Address - Fax:203-401-4687
Practice Address - Street 1:40 TEMPLE ST
Practice Address - Street 2:SUITE 4A
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-2715
Practice Address - Country:US
Practice Address - Phone:203-777-0304
Practice Address - Fax:203-401-4687
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000907363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTP40174Medicare UPIN
CT970000888Medicare ID - Type Unspecified