Basic Information
| Provider Information | |||||||||
| NPI: | 1114975380 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SKOLNICK | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | N. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 736 CAMBRIDGE ST | ||||||||
| Address2: | CARITAS MEDICAL GROUP | ||||||||
| City: | BRIGHTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021352907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172964000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2100 DORCHESTER AVE | ||||||||
| Address2: | CANTAS CARNEY HOSPITAL | ||||||||
| City: | DORCHESTER CENTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021245615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172964000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 04/21/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 208549 | MA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110002643A | 05 | MA | MEDICAID |