Provider Demographics
NPI:1053928044
Name:VAN DYCK, JENNA (PA-C)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:VAN DYCK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06412-1340
Mailing Address - Country:US
Mailing Address - Phone:860-358-5005
Mailing Address - Fax:860-358-8651
Practice Address - Street 1:150 MAIN ST
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:CT
Practice Address - Zip Code:06412-1340
Practice Address - Country:US
Practice Address - Phone:860-358-5005
Practice Address - Fax:860-358-8651
Is Sole Proprietor?:No
Enumeration Date:2020-09-24
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1170894363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant