Provider Demographics
NPI:1700481413
Name:MCMICKEN, JENNIFER GABRIELA CABRAL
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:GABRIELA CABRAL
Last Name:MCMICKEN
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 1:817 BANK ST
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-3503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:817 BANK ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-3503
Practice Address - Country:US
Practice Address - Phone:860-443-5359
Practice Address - Fax:860-440-3336
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRPH06401183500000X
MAPH240627183500000X
MAPI165412183700000X
CT0016569183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No183700000XPharmacy Service ProvidersPharmacy Technician