Healthcare Provider Details

I. General information

NPI: 1255667796
Provider Name (Legal Business Name): JACLENE RAYMOND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2009
Last Update Date: 05/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 S RIVER RD STE 100
BEDFORD NH
03110
US

IV. Provider business mailing address

160 S RIVER RD STE 101
BEDFORD NH
03110-6927
US

V. Phone/Fax

Practice location:
  • Phone: 603-647-0494
  • Fax: 603-647-0493
Mailing address:
  • Phone: 603-647-0494
  • Fax: 603-647-0493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number062520-21
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2262268
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number062520-23
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: