Healthcare Provider Details

I. General information

NPI: 1295647741
Provider Name (Legal Business Name): JACOB RICHARD NOWAK FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 ANDREWS WAY
SOUTHBOROUGH MA
01772-1024
US

IV. Provider business mailing address

6 ANDREWS WAY
SOUTHBOROUGH MA
01772-1024
US

V. Phone/Fax

Practice location:
  • Phone: 774-262-5700
  • Fax:
Mailing address:
  • Phone: 774-262-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2356627
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: