Provider Demographics
NPI:1588028153
Name:STANFORD, JENNIE THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIE
Middle Name:THOMAS
Last Name:STANFORD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:NEW CANAAN
Mailing Address - State:CT
Mailing Address - Zip Code:06840-5325
Mailing Address - Country:US
Mailing Address - Phone:844-359-8363
Mailing Address - Fax:833-929-3520
Practice Address - Street 1:69 GROVE ST
Practice Address - Street 2:
Practice Address - City:NEW CANAAN
Practice Address - State:CT
Practice Address - Zip Code:06840-5325
Practice Address - Country:US
Practice Address - Phone:844-359-8363
Practice Address - Fax:833-929-3520
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-11
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1992372403261QM2500X
CT1992372403261QM2500X
NY1043889967261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07129501Medicaid