Provider Demographics
NPI:1861109407
Name:JILL DUBOFF-JACOMINI APRN, PLLC
Entity type:Organization
Organization Name:JILL DUBOFF-JACOMINI APRN, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:DUBOFF-JACOMINI
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:860-712-8863
Mailing Address - Street 1:75 POND SIDE DR
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-4153
Mailing Address - Country:US
Mailing Address - Phone:860-712-8863
Mailing Address - Fax:
Practice Address - Street 1:816 BROAD ST STE 23
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-4350
Practice Address - Country:US
Practice Address - Phone:860-712-8863
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-02
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT800OtherAPRN LICENSE