Healthcare Provider Details

I. General information

NPI: 1710667712
Provider Name (Legal Business Name): JENNIFER NICOLE DEPATIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2023
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST WHITE 1
BOSTON MA
02114-2696
US

IV. Provider business mailing address

9 JACKSON ST
HOPKINTON MA
01748-2568
US

V. Phone/Fax

Practice location:
  • Phone: 617-724-4100
  • Fax: 617-726-7415
Mailing address:
  • Phone: 774-278-8272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA101071
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: