Provider Demographics
NPI:1598195216
Name:CAPSTICK, JENNIFER L (OD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:CAPSTICK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 QUARRY ST
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-1238
Mailing Address - Country:US
Mailing Address - Phone:860-423-1619
Mailing Address - Fax:860-423-7640
Practice Address - Street 1:83 QUARRY ST
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-1238
Practice Address - Country:US
Practice Address - Phone:860-423-1619
Practice Address - Fax:860-423-7640
Is Sole Proprietor?:No
Enumeration Date:2013-11-15
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00646000152W00000X
CT3067152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT3067OtherSTATE LICENSE
NJ27OA00646000OtherSTATE LICENSE
CTCSP.0067484OtherSTATE CONTROLLED SUBSTANCE LICENSE