Basic Information
| Provider Information | |||||||||
| NPI: | 1174627236 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JENCKS | ||||||||
| FirstName: | PRISCILLA | ||||||||
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| Credential: | LNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 87 INGRAM STREET | ||||||||
| Address2: | |||||||||
| City: | HAMDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032879706 | ||||||||
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| Practice Location | |||||||||
| Address1: | 374 GRAND AVE | ||||||||
| Address2: | FAIR HAVEN COMMUNITY HEALTH CTR | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037777411 | ||||||||
| FaxNumber: | 2037778604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 000071 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 0000254189301 | 01 | UNITED HEALTHCARE | OTHER | 0000719734 | 01 | CT CARE | OTHER | P3597631 | 01 | OXFORD | OTHER | 400000071CT01 | 01 | ANTHEM BCBS | OTHER |