Provider Demographics
NPI:1811666308
Name:STANISH, JENNA SUE
Entity type:Individual
Prefix:MISS
First Name:JENNA
Middle Name:SUE
Last Name:STANISH
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 1:13 PORTER RD
Mailing Address - Street 2:
Mailing Address - City:WOLCOTT
Mailing Address - State:CT
Mailing Address - Zip Code:06716-1414
Mailing Address - Country:US
Mailing Address - Phone:203-707-3052
Mailing Address - Fax:
Practice Address - Street 1:13 PORTER RD
Practice Address - Street 2:
Practice Address - City:WOLCOTT
Practice Address - State:CT
Practice Address - Zip Code:06716-1414
Practice Address - Country:US
Practice Address - Phone:203-707-3052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer