Provider Demographics
NPI:1588808521
Name:COHEN, JENNIFER EDYTHE (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:EDYTHE
Last Name:COHEN
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 1:120 MAIN ST FL 4
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-7834
Mailing Address - Country:US
Mailing Address - Phone:203-743-0100
Mailing Address - Fax:203-743-3411
Practice Address - Street 1:120 MAIN ST FL 4
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-7834
Practice Address - Country:US
Practice Address - Phone:203-743-0100
Practice Address - Fax:203-743-3411
Is Sole Proprietor?:No
Enumeration Date:2009-04-21
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT53222207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGR612YMedicare PIN
12413295OtherCAQH
FL006446000Medicaid