1790379972 NPI number — JACQUELYN ROBERTS MSN, APRN, FNP-C,

Table of content: JACQUELYN ROBERTS MSN, APRN, FNP-C, (NPI 1790379972)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790379972 NPI number — JACQUELYN ROBERTS MSN, APRN, FNP-C,

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTS
Provider First Name:
JACQUELYN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSN, APRN, FNP-C,
Provider Gender Code:
F

Provider's Other Name Information

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

NPI Number Information

NPI Number:
1790379972
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
39 MITCHELL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEDFORD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02155-1736
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-808-4757
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11 SALEM ST STE 15
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02155-3262
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-299-0440
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/27/2021

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: 363L00000X , with the licence number:  RN2310867 , 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)





Copyright © 2007-2025 www.npivalidator.com