Provider Demographics
NPI:1720428949
Name:ORTIZ-SKENDERIDIS, JACQUELINE (APRN)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:ORTIZ-SKENDERIDIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 N MAIN ST STE 110
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-1932
Mailing Address - Country:US
Mailing Address - Phone:860-337-9800
Mailing Address - Fax:860-263-7329
Practice Address - Street 1:12 N MAIN ST STE 110
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-1932
Practice Address - Country:US
Practice Address - Phone:860-337-9800
Practice Address - Fax:860-263-7329
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-02
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005364363LF0000X
CT5364363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily