Provider Demographics
NPI:1629271192
Name:MCCALLISTER, JENNIFER NOELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:NOELLE
Last Name:MCCALLISTER
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 1:105 S FARMS DR
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-6676
Mailing Address - Country:US
Mailing Address - Phone:860-432-5960
Mailing Address - Fax:
Practice Address - Street 1:40 HART ST
Practice Address - Street 2:BUILDING D
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06052-1743
Practice Address - Country:US
Practice Address - Phone:860-224-5430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT045391208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery