Provider Demographics
NPI:1730728619
Name:DANIELS, JAMAL (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:JAMAL
Middle Name:
Last Name:DANIELS
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:JAMAL
Other - Middle Name:
Other - Last Name:ATHARI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11 SQUAW HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:ASHFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06278-1546
Mailing Address - Country:US
Mailing Address - Phone:860-455-5781
Mailing Address - Fax:
Practice Address - Street 1:80 SEYMOUR ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06102-8000
Practice Address - Country:US
Practice Address - Phone:860-972-9047
Practice Address - Fax:860-972-7040
Is Sole Proprietor?:No
Enumeration Date:2019-12-25
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT9064363LA2100X
CT10.126810163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WE0003XNursing Service ProvidersRegistered NurseEmergency