Healthcare Provider Details

I. General information

NPI: 1982142519
Provider Name (Legal Business Name): JESSICA JEANNE SULLIVAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JESSICA JEANNE SULLIVAN RN

II. Dates (important events)

Enumeration Date: 02/02/2017
Last Update Date: 06/10/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FOGG RD
WEYMOUTH MA
02190-2432
US

IV. Provider business mailing address

55 FOGG RD
WEYMOUTH MA
02190-2432
US

V. Phone/Fax

Practice location:
  • Phone: 781-624-8000
  • Fax:
Mailing address:
  • Phone: 781-624-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2306549
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberRN2306549
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: