Provider Demographics
NPI:1912495797
Name:WEBB, JENNIE (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:WEBB
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2247 E MAIN ST STE 103
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06705-2604
Mailing Address - Country:US
Mailing Address - Phone:203-757-3486
Mailing Address - Fax:203-757-3723
Practice Address - Street 1:2247 E MAIN ST STE 103
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06705
Practice Address - Country:US
Practice Address - Phone:203-212-9696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-26
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA6403363A00000X
CT004248363AM0700X
CT4248363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical