Provider Demographics
NPI:1659543650
Name:EVENSON, M JEANNE (AUD)
Entity Type:Individual
Prefix:MRS
First Name:M JEANNE
Middle Name:
Last Name:EVENSON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 TAMARACK AVENUE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074
Mailing Address - Country:US
Mailing Address - Phone:860-648-2802
Mailing Address - Fax:860-648-0870
Practice Address - Street 1:2800 TAMARACK AVENUE
Practice Address - Street 2:SUITE 102
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074
Practice Address - Country:US
Practice Address - Phone:860-648-2802
Practice Address - Fax:860-648-0870
Is Sole Proprietor?:No
Enumeration Date:2008-03-31
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000463231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist