Healthcare Provider Details

I. General information

NPI: 1225006398
Provider Name (Legal Business Name): JENNIFER WILLIAMS MACK MD MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER LEE WILLIAMS

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 03/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 BINNEY ST 454 SUITE 21
BOSTON MA
02115
US

IV. Provider business mailing address

450 BROOKLINE AVE DANA 11
BOSTON MA
02215-5418
US

V. Phone/Fax

Practice location:
  • Phone: 617-632-6818
  • Fax: 617-632-2270
Mailing address:
  • Phone: 617-632-6818
  • Fax: 617-632-2270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number212529
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: