Healthcare Provider Details

I. General information

NPI: 1619791027
Provider Name (Legal Business Name): JENNIFER KELLY PLOURDE PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2024
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 PERFORMANCE DR
WEYMOUTH MA
02189-3141
US

IV. Provider business mailing address

1686 WASHINGTON ST
CANTON MA
02021-1640
US

V. Phone/Fax

Practice location:
  • Phone: 781-682-0530
  • Fax:
Mailing address:
  • Phone: 781-571-1051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number18458
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: