Healthcare Provider Details

I. General information

NPI: 1285615617
Provider Name (Legal Business Name): JENNIFER AI-WEN CHAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/11/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 FRANCIS ST DEPARTMENT OF PATHOLOGY, BRIGHAM AND WOMEN'S HOSPITAL
BOSTON MA
02115-6110
US

IV. Provider business mailing address

21 RANDOLPH ST
NEWTON MA
02461-1308
US

V. Phone/Fax

Practice location:
  • Phone: 617-732-7532
  • Fax: 617-975-0944
Mailing address:
  • Phone: 617-244-3863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZN0500X
TaxonomyNeuropathology Physician
License Number213540
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number213540
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: