Provider Demographics
NPI:1700921228
Name:EVANGELISTE, JENNIFER (OTR)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:EVANGELISTE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 ELM ST
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-2808
Mailing Address - Country:US
Mailing Address - Phone:203-250-9663
Mailing Address - Fax:
Practice Address - Street 1:209 CHERRY ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-3501
Practice Address - Country:US
Practice Address - Phone:203-874-5437
Practice Address - Fax:203-301-9552
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002425225XP0200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics