Healthcare Provider Details

I. General information

NPI: 1497373799
Provider Name (Legal Business Name): IFE JAHA TRACY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2020
Last Update Date: 08/23/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 MASSACHUSETTS AVE # 3448-A BOSTON UNIVERSITY FAMILY MEDICINE;VALUE BASED PROGRAM
BOSTON MA
02118-2620
US

IV. Provider business mailing address

960 MASSACHUSETTS AVE STE 2
BOSTON MA
02118-2690
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-2080
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2299747
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN2299747
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: