Healthcare Provider Details

I. General information

NPI: 1154134393
Provider Name (Legal Business Name): JESSICA FERNANDES CANUTO AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2025
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 EDSON ST
BROCKTON MA
02302-4109
US

IV. Provider business mailing address

45 EDSON ST
BROCKTON MA
02302-4109
US

V. Phone/Fax

Practice location:
  • Phone: 774-274-1882
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberRN2361476
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: