Basic Information
| Provider Information | |||||||||
| NPI: | 1629301718 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACOBS | ||||||||
| FirstName: | RENA | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRYAN | ||||||||
| OtherFirstName: | RENA | ||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 28 CRESCENT ST | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064573654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603584820 | ||||||||
| FaxNumber: | 8603588661 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064222126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603491058 | ||||||||
| FaxNumber: | 8603588652 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2009 | ||||||||
| LastUpdateDate: | 04/12/2017 | ||||||||
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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 | 363A00000X | 002304 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 008016826 | 05 | CT | MEDICAID |