Basic Information
| Provider Information | |||||||||
| NPI: | 1235375114 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLARD | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | HASTINGS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | THOMAS | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | HASTINGS | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APRN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 789 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038202526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036642135 | ||||||||
| FaxNumber: | 6036649128 | ||||||||
| Practice Location | |||||||||
| Address1: | 8 CENTURY PINES DR | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | BARRINGTON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038253732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036642135 | ||||||||
| FaxNumber: | 6036649128 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2008 | ||||||||
| LastUpdateDate: | 02/19/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | 060461-23 | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 3075371 | 05 | NH | MEDICAID | 1235375114 | 05 | ME | MEDICAID | P00709637 | 01 | NH | RR MEDICARE | OTHER |