Provider Demographics
NPI:1336278043
Name:NIELDS, JENIFER A (MD)
Entity Type:Individual
Prefix:
First Name:JENIFER
Middle Name:A
Last Name:NIELDS
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 1:108 OLD ORCHARD PARK
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-6606
Mailing Address - Country:US
Mailing Address - Phone:203-259-5812
Mailing Address - Fax:203-259-9849
Practice Address - Street 1:108 OLD ORCHARD PARK
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-6606
Practice Address - Country:US
Practice Address - Phone:203-259-5812
Practice Address - Fax:203-259-9849
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0292062084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT260002111Medicare PIN