Healthcare Provider Details

I. General information

NPI: 1801107446
Provider Name (Legal Business Name): JENNIFER E DEANE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2010
Last Update Date: 12/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 MALL RD LAHEY CLINIC
BURLINGTON MA
01805-0001
US

IV. Provider business mailing address

41 MALL RD LAHEY CLINIC
BURLINGTON MA
01805-0001
US

V. Phone/Fax

Practice location:
  • Phone: 781-744-8583
  • Fax: 781-744-1052
Mailing address:
  • Phone: 781-744-8583
  • Fax: 781-744-1052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-266
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA4503
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: