Basic Information
| Provider Information | |||||||||
| NPI: | 1326349820 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AMMERMAN | ||||||||
| FirstName: | JESSYCA | ||||||||
| MiddleName: | LYN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KNEEN | ||||||||
| OtherFirstName: | JESSYCA | ||||||||
| OtherMiddleName: | LYN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2928 MAIN STREET | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | GLASTONBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604301246 | ||||||||
| FaxNumber: | 2039056824 | ||||||||
| Practice Location | |||||||||
| Address1: | 2165 DIXWELL AVE | ||||||||
| Address2: | |||||||||
| City: | HAMDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065142116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032482727 | ||||||||
| FaxNumber: | 2036919673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2010 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 002491 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 002491 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.