Provider Demographics
NPI:1548917594
Name:REVIVE CENTER FOR HEALTH & WELLNESS, PLLC
Entity type:Organization
Organization Name:REVIVE CENTER FOR HEALTH & WELLNESS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:MARIA SOUSA
Authorized Official - Last Name:JEROME
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, APRN, FNP-BC
Authorized Official - Phone:860-375-2227
Mailing Address - Street 1:281 HARTFORD TPKE STE 106
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-4760
Mailing Address - Country:US
Mailing Address - Phone:860-375-2227
Mailing Address - Fax:
Practice Address - Street 1:281 HARTFORD TPKE STE 106
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-4760
Practice Address - Country:US
Practice Address - Phone:860-375-2227
Practice Address - Fax:860-603-5080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-09
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1134661531Medicaid