Healthcare Provider Details

I. General information

NPI: 1376465153
Provider Name (Legal Business Name): JENNA LEE NICKERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 LINCOLN SQ
WORCESTER MA
01608-1135
US

IV. Provider business mailing address

100 HICKORY RD
WRENTHAM MA
02093-1075
US

V. Phone/Fax

Practice location:
  • Phone: 774-210-0837
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: