Provider Demographics
NPI:1063621829
Name:SUTHERLAND, JENNIFER LYN (MD, MPH)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYN
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:28 CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3654
Mailing Address - Country:US
Mailing Address - Phone:860-358-6000
Mailing Address - Fax:860-358-8661
Practice Address - Street 1:250 FLAT ROCK PLACE
Practice Address - Street 2:PHYS OFF 1
Practice Address - City:WESTBROOK
Practice Address - State:CT
Practice Address - Zip Code:06498-3585
Practice Address - Country:US
Practice Address - Phone:860-358-3640
Practice Address - Fax:860-358-8656
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA232049207Q00000X
CT051698207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008050305Medicaid
CT008050305Medicaid
CTD400326499Medicare UPIN