Healthcare Provider Details

I. General information

NPI: 1356893689
Provider Name (Legal Business Name): KATHLEEN ANNE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2016
Last Update Date: 11/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2621
US

IV. Provider business mailing address

160 OSGOOD ST
ANDOVER MA
01810-5410
US

V. Phone/Fax

Practice location:
  • Phone: 617-724-0969
  • Fax:
Mailing address:
  • Phone: 978-623-3387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number164460
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: