Healthcare Provider Details

I. General information

NPI: 1851651087
Provider Name (Legal Business Name): JENNIFER LI D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2012
Last Update Date: 08/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2345 MAIN ST
TEWKSBURY MA
01876-3125
US

IV. Provider business mailing address

2345 MAIN ST
TEWKSBURY MA
01876-3125
US

V. Phone/Fax

Practice location:
  • Phone: 978-658-9931
  • Fax:
Mailing address:
  • Phone: 978-658-9931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number262593
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: