Provider Demographics
NPI:1134619414
Name:MASON, JESSICA (DO)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MASON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:462 QUEEN ST # 301
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-1801
Mailing Address - Country:US
Mailing Address - Phone:203-623-5402
Mailing Address - Fax:
Practice Address - Street 1:462 QUEEN ST # 301
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-1801
Practice Address - Country:US
Practice Address - Phone:860-621-6704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-13
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT67545207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine