Provider Demographics
NPI:1316689078
Name:VICENTE, JACOB (DNP, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:VICENTE
Suffix:
Gender:M
Credentials:DNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:836 FARMINGTON AVE STE 109
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-1544
Mailing Address - Country:US
Mailing Address - Phone:203-691-1685
Mailing Address - Fax:203-891-6763
Practice Address - Street 1:836 FARMINGTON AVE STE 109
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119-1544
Practice Address - Country:US
Practice Address - Phone:203-691-1685
Practice Address - Fax:203-891-6763
Is Sole Proprietor?:No
Enumeration Date:2022-04-12
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2309147163WH0500X, 363LP0808X
CT14685363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WH0500XNursing Service ProvidersRegistered NurseHemodialysis