Provider Demographics
NPI:1366799587
Name:PAULSON, JESSICA L (PA-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:PAULSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:L
Other - Last Name:PERREAULT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
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:860-358-4820
Mailing Address - Fax:860-358-8661
Practice Address - Street 1:1347 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-3475
Practice Address - Country:US
Practice Address - Phone:203-779-5207
Practice Address - Fax:203-779-5792
Is Sole Proprietor?:No
Enumeration Date:2012-08-07
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2784363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008043666Medicaid
CT008043666Medicaid