Provider Demographics
NPI:1699361824
Name:COSMOPOULOS, JENNIFER DAWN
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DAWN
Last Name:COSMOPOULOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 CHARLTON LN
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-7707
Mailing Address - Country:US
Mailing Address - Phone:860-367-7838
Mailing Address - Fax:
Practice Address - Street 1:82 NEW PARK AVE
Practice Address - Street 2:
Practice Address - City:NORTH FRANKLIN
Practice Address - State:CT
Practice Address - Zip Code:06254-1807
Practice Address - Country:US
Practice Address - Phone:860-367-7838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-11
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0064322081P0010X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation Medicine