Basic Information
Provider Information | |||||||||
NPI: | 1083846760 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RICHARDSON | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 362 N BEDFORD ST | ||||||||
Address2: |   | ||||||||
City: | EAST BRIDGEWATER | ||||||||
State: | MA | ||||||||
PostalCode: | 023331148 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5083502350 | ||||||||
FaxNumber: | 5083502318 | ||||||||
Practice Location | |||||||||
Address1: | 1 COMPASS WAY | ||||||||
Address2: | SUITE 210 | ||||||||
City: | EAST BRIDGEWATER | ||||||||
State: | MA | ||||||||
PostalCode: | 023331465 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5083502300 | ||||||||
FaxNumber: | 5083502307 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/14/2009 | ||||||||
LastUpdateDate: | 12/17/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 2009007598 | MA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 110093072A | 01 | MA | MASSHEALTH | OTHER | 002002704 | 01 | MA | MEDICARE | OTHER |