Provider Demographics
NPI:1184263493
Name:ANTIPOFF, JENNA WORGUL
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:WORGUL
Last Name:ANTIPOFF
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 1:1 RAINBOW CT
Mailing Address - Street 2:
Mailing Address - City:QUAKER HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06375-1341
Mailing Address - Country:US
Mailing Address - Phone:860-460-7012
Mailing Address - Fax:
Practice Address - Street 1:900 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-2136
Practice Address - Country:US
Practice Address - Phone:860-388-0022
Practice Address - Fax:860-395-2484
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-03
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT437237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist