=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952885816
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACQUELINE ANN BERUBE CNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2018
-----------------------------------------------------
Last Update Date | 08/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 SOUTH ST
-----------------------------------------------------
City | SOUTHBRIDGE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01550-4051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-765-9771
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 64 ALLEN RD
-----------------------------------------------------
City | STURBRIDGE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01566-1018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | RN211198
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | RN211198
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------