Provider Demographics
NPI:1558402230
Name:DODGE, JENNIFER S (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:S
Last Name:DODGE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-1328
Mailing Address - Country:US
Mailing Address - Phone:203-736-9919
Mailing Address - Fax:203-735-2055
Practice Address - Street 1:22 WESTFIELD AVE
Practice Address - Street 2:
Practice Address - City:ANSONIA
Practice Address - State:CT
Practice Address - Zip Code:06401-1158
Practice Address - Country:US
Practice Address - Phone:203-736-9919
Practice Address - Fax:203-735-2055
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT907363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTP40174Medicare UPIN
CT970000888Medicare ID - Type Unspecified