Provider Demographics
NPI:1801307475
Name:PELLETIER, JESSICA MAGDALENA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MAGDALENA
Last Name:PELLETIER
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 1:166 WATERBURY RD STE 104
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:CT
Mailing Address - Zip Code:06712-1246
Mailing Address - Country:US
Mailing Address - Phone:203-756-6422
Mailing Address - Fax:
Practice Address - Street 1:166 WATERBURY RD STE 104
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:CT
Practice Address - Zip Code:06712-1246
Practice Address - Country:US
Practice Address - Phone:203-756-6422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-23
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant