Provider Demographics
NPI:1245478999
Name:AVEDISIAN, JENNIFER ROCH
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ROCH
Last Name:AVEDISIAN
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 1:3461 S COUNTY TRL STE 301
Mailing Address - Street 2:
Mailing Address - City:EAST GREENWICH
Mailing Address - State:RI
Mailing Address - Zip Code:02818-1463
Mailing Address - Country:US
Mailing Address - Phone:401-471-6760
Mailing Address - Fax:
Practice Address - Street 1:350 LIBERTY ST STE 102
Practice Address - Street 2:
Practice Address - City:PAWCATUCK
Practice Address - State:CT
Practice Address - Zip Code:06379-1354
Practice Address - Country:US
Practice Address - Phone:860-599-9961
Practice Address - Fax:860-972-7040
Is Sole Proprietor?:No
Enumeration Date:2009-02-02
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIAPRN00993363LF0000X
CT12089363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily