Healthcare Provider Details

I. General information

NPI: 1215148606
Provider Name (Legal Business Name): JENNA CHRISTINA DISTASIO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 08/19/2020
Certification Date: 08/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 PARKER HILL AVE
ROXBURY CROSSING MA
02120-3215
US

IV. Provider business mailing address

20 GUEST ST STE 225
BRIGHTON MA
02135-2065
US

V. Phone/Fax

Practice location:
  • Phone: 617-754-6742
  • Fax: 617-754-6443
Mailing address:
  • Phone: 617-738-8642
  • Fax: 617-202-4172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2229
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: