Provider Demographics
NPI:1720270119
Name:JACKSON, SEJA JOYCE (PHD, APRN, AAHIVS)
Entity Type:Individual
Prefix:DR
First Name:SEJA
Middle Name:JOYCE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD, APRN, AAHIVS
Other - Prefix:MS
Other - First Name:JOYCE
Other - Middle Name:SHARON
Other - Last Name:FISHMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, APRN, AAHIVS
Mailing Address - Street 1:95 WOODBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-2924
Mailing Address - Country:US
Mailing Address - Phone:860-633-5803
Mailing Address - Fax:860-714-8541
Practice Address - Street 1:131 COVENTRY ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06112-1548
Practice Address - Country:US
Practice Address - Phone:860-714-2862
Practice Address - Fax:860-714-8541
Is Sole Proprietor?:No
Enumeration Date:2007-08-10
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001601363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health