Provider Demographics
NPI:1598110215
Name:JERSEY, CANDICE G (DO)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:G
Last Name:JERSEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:CANDICE
Other - Middle Name:G
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:263 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-0002
Mailing Address - Country:US
Mailing Address - Phone:860-679-2147
Mailing Address - Fax:
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-1530
Practice Address - Country:US
Practice Address - Phone:860-679-2147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-02
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT63814208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program