Provider Demographics
NPI:1700060787
Name:HAILE, JENNIFER TORP (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:TORP
Last Name:HAILE
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 1:169 FARMDALE ROAD
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06795-2632
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:76 NEW BRITAIN AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-3305
Practice Address - Country:US
Practice Address - Phone:860-545-9300
Practice Address - Fax:860-837-6801
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-26
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPGY.1.TUL-PEDS390200000X
LAMD.203198208000000X
CT050760208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1700060787Medicaid
LA1003051Medicaid
MS01578320Medicaid
LA1003051Medicaid