Basic Information
| Provider Information | |||||||||
| NPI: | 1134536055 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PENNIE | ||||||||
| FirstName: | JACQUELYN | ||||||||
| MiddleName: | ELISE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DESJARDINS | ||||||||
| OtherFirstName: | JACQUELYN | ||||||||
| OtherMiddleName: | ELISE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1 LYONS STREET | ||||||||
| Address2: | ATRIUS HEALTH, INC | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176576495 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 LYONS ST | ||||||||
| Address2: | |||||||||
| City: | DEDHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020265599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088800012 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2014 | ||||||||
| LastUpdateDate: | 09/13/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA5064 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.