Provider Demographics
NPI:1780120949
Name:BUDLOWSKI, JACQUELYN SHIRLEY (PA-C, RD, CDN)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:SHIRLEY
Last Name:BUDLOWSKI
Suffix:
Gender:F
Credentials:PA-C, RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 SHELVIEW DR
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-4232
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:131 KENT RD
Practice Address - Street 2:
Practice Address - City:NEW MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06776-3485
Practice Address - Country:US
Practice Address - Phone:860-355-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-12
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1486133V00000X
CT4854363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant