Basic Information
| Provider Information | |||||||||
| NPI: | 1033309588 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACRIE | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | WEBSTER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1290 SILAS DEANE HWY FL 1 | ||||||||
| Address2: | |||||||||
| City: | WETHERSFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061094337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609726970 | ||||||||
| FaxNumber: | 8609727040 | ||||||||
| Practice Location | |||||||||
| Address1: | 73 WATERBURY ROAD | ||||||||
| Address2: | |||||||||
| City: | SUITE 1 | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061094337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035279444 | ||||||||
| FaxNumber: | 2035279332 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2007 | ||||||||
| LastUpdateDate: | 09/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 134164 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 64340 | CT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64340 | 01 | CT | CT LIC | OTHER |