Healthcare Provider Details

I. General information

NPI: 1639877822
Provider Name (Legal Business Name): JENNIFER TO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2023
Last Update Date: 02/20/2025
Certification Date: 02/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 WASHINGTON ST STE 101
BRAINTREE MA
02184-4764
US

IV. Provider business mailing address

400 WASHINGTON ST STE 101
BRAINTREE MA
02184-4764
US

V. Phone/Fax

Practice location:
  • Phone: 781-767-0910
  • Fax:
Mailing address:
  • Phone: 781-767-0910
  • Fax: 781-767-0921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number71931
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: