Provider Demographics
NPI:1629301718
Name:JACOBS, RENA (PA)
Entity Type:Individual
Prefix:
First Name:RENA
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:RENA
Other - Middle Name:
Other - Last Name:BRYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:28 CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3654
Mailing Address - Country:US
Mailing Address - Phone:860-358-4820
Mailing Address - Fax:860-358-8661
Practice Address - Street 1:6 MAIN ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:CT
Practice Address - Zip Code:06422-2126
Practice Address - Country:US
Practice Address - Phone:860-349-1058
Practice Address - Fax:860-358-8652
Is Sole Proprietor?:No
Enumeration Date:2009-09-08
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002304363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008016826Medicaid
CTD400009772Medicare PIN