Healthcare Provider Details

I. General information

NPI: 1245565373
Provider Name (Legal Business Name): RENATA JEWER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2009
Last Update Date: 10/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 WESTPORT RD
WORCESTER MA
01605-1051
US

IV. Provider business mailing address

19 TACOMA ST GREAT BROOK VALLEY HEALTH CENTER
WORCESTER MA
01605
US

V. Phone/Fax

Practice location:
  • Phone: 774-242-6246
  • Fax:
Mailing address:
  • Phone: 508-852-1805
  • Fax: 508-853-8593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN284795
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: