Provider Demographics
NPI:1740608207
Name:LETITIA, JENNIFER O (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:O
Last Name:LETITIA
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 1:1 TULIP LN
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-2734
Mailing Address - Country:US
Mailing Address - Phone:203-293-5618
Mailing Address - Fax:
Practice Address - Street 1:501 KINGS HWY E STE 108
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-4870
Practice Address - Country:US
Practice Address - Phone:203-371-0300
Practice Address - Fax:203-680-9242
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0343912082S0105X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT23085OtherCSP
CTBP6812362OtherDEA