1720270119 NPI number — DR. SEJA JOYCE JACKSON PHD, APRN, AAHIVS

Table of content: DR. SEJA JOYCE JACKSON PHD, APRN, AAHIVS (NPI 1720270119)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720270119 NPI number — DR. SEJA JOYCE JACKSON PHD, APRN, AAHIVS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
SEJA
Provider Middle Name:
JOYCE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD, APRN, AAHIVS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FISHMAN
Provider Other First Name:
JOYCE
Provider Other Middle Name:
SHARON
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS, APRN, AAHIVS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1720270119
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/24/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
95 WOODBRIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLASTONBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06033-2924
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-633-5803
Provider Business Mailing Address Fax Number:
860-714-8541

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
131 COVENTRY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARTFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06112-1548
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-714-2862
Provider Business Practice Location Address Fax Number:
860-714-8541
Provider Enumeration Date:
08/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  001601 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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