Provider Demographics
NPI:1992774384
Name:HEN, JACOB JR (MD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:HEN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5520 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611
Mailing Address - Country:US
Mailing Address - Phone:203-337-8600
Mailing Address - Fax:203-372-0109
Practice Address - Street 1:5520 PARK AVE
Practice Address - Street 2:NEMG
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-3463
Practice Address - Country:US
Practice Address - Phone:203-337-8600
Practice Address - Fax:203-372-0109
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0207102080P0214X, 2080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001207100Medicaid
CT001207100Medicaid
CT370000696Medicare ID - Type Unspecified