Provider Demographics
NPI:1619035243
Name:JOSE, JENNIFER G (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:G
Last Name:JOSE
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 1:688 BOSTON POST RD
Mailing Address - Street 2:
Mailing Address - City:DARIEN
Mailing Address - State:CT
Mailing Address - Zip Code:06820-4717
Mailing Address - Country:US
Mailing Address - Phone:203-662-9602
Mailing Address - Fax:203-662-0061
Practice Address - Street 1:688 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:DARIEN
Practice Address - State:CT
Practice Address - Zip Code:06820-4717
Practice Address - Country:US
Practice Address - Phone:203-662-9602
Practice Address - Fax:203-662-0061
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT037301207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTH05077Medicare UPIN
CT110007723Medicare ID - Type UnspecifiedMEDICARE NUMBER