Provider Demographics
NPI:1609493311
Name:YENTZ, JESSICA DEANNE (FNP-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:DEANNE
Last Name:YENTZ
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 HAWLEY LN FL CB34273
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-1202
Mailing Address - Country:US
Mailing Address - Phone:203-502-4650
Mailing Address - Fax:
Practice Address - Street 1:50 FAIRE HARBOUR PL
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4731
Practice Address - Country:US
Practice Address - Phone:860-771-4960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-29
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28229593A207Q00000X
CT9211207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine