Healthcare Provider Details

I. General information

NPI: 1952885816
Provider Name (Legal Business Name): JACQUELINE ANN BERUBE CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2018
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SOUTH ST
SOUTHBRIDGE MA
01550-4051
US

IV. Provider business mailing address

64 ALLEN RD
STURBRIDGE MA
01566-1018
US

V. Phone/Fax

Practice location:
  • Phone: 508-765-9771
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN211198
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN211198
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: