Healthcare Provider Details

I. General information

NPI: 1194127704
Provider Name (Legal Business Name): JACQUELINE WULU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2014
Last Update Date: 01/07/2022
Certification Date: 01/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 HARRISON AVE
BOSTON MA
02118-4001
US

IV. Provider business mailing address

840 HARRISON AVE
BOSTON MA
02118-2905
US

V. Phone/Fax

Practice location:
  • Phone: 617-638-7066
  • Fax:
Mailing address:
  • Phone: 617-638-6800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number264293
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: