Provider Demographics
NPI:1013474261
Name:SEVERENKO, JENNIFER PARK
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:PARK
Last Name:SEVERENKO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-6099
Mailing Address - Country:US
Mailing Address - Phone:203-739-7118
Mailing Address - Fax:203-749-9030
Practice Address - Street 1:24 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-6099
Practice Address - Country:US
Practice Address - Phone:203-739-7118
Practice Address - Fax:203-749-9030
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-25
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12.008590367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered