Provider Demographics
NPI:1932802535
Name:HADDAD, JENNIFER IRENE (LO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:IRENE
Last Name:HADDAD
Suffix:
Gender:F
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1252 TRUMBULL HWY
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:CT
Mailing Address - Zip Code:06249-1534
Mailing Address - Country:US
Mailing Address - Phone:413-388-2973
Mailing Address - Fax:
Practice Address - Street 1:1252 TRUMBULL HWY
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:CT
Practice Address - Zip Code:06249-1534
Practice Address - Country:US
Practice Address - Phone:413-388-2973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-23
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1824156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician