1467447300 NPI number — NICOLE JARDIN PECQUEX M.D.

Table of content: NICOLE JARDIN PECQUEX M.D. (NPI 1467447300)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467447300 NPI number — NICOLE JARDIN PECQUEX M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PECQUEX
Provider First Name:
NICOLE
Provider Middle Name:
JARDIN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JARDIN
Provider Other First Name:
NICOLE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1467447300
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/14/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
960 MASSACHUSETTS AVE
Provider Second Line Business Mailing Address:
FL 2
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02118-2690
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11 NEVINS ST
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
BRIGHTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02135-3514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-789-2442
Provider Business Practice Location Address Fax Number:
617-202-4349
Provider Enumeration Date:
09/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  219025 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2031370 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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