Healthcare Provider Details

I. General information

NPI: 1841727005
Provider Name (Legal Business Name): JESSICA LACROIX
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2017
Last Update Date: 12/30/2021
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2621
US

IV. Provider business mailing address

4 RIDGE ST
MILLIS MA
02054-1108
US

V. Phone/Fax

Practice location:
  • Phone: 617-323-7700
  • Fax: 617-726-2000
Mailing address:
  • Phone: 508-314-3111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN2313652
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAG11210088
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: