Healthcare Provider Details

I. General information

NPI: 1093057580
Provider Name (Legal Business Name): JENNIFER MASSARELLI NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. JENNIFER HALL

II. Dates (important events)

Enumeration Date: 03/22/2013
Last Update Date: 10/25/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 FULLER RD
ANN ARBOR MI
48105-2303
US

IV. Provider business mailing address

55 LAKE AVE N UMASS MEMORIAL MEDICAL CENTER, PSYCHIATRY
WORCESTER MA
01655-0002
US

V. Phone/Fax

Practice location:
  • Phone: 734-769-7100
  • Fax:
Mailing address:
  • Phone: 508-334-3562
  • Fax: 508-421-1000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number276298
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN276298
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704344082
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: