Basic Information
| Provider Information | |||||||||
| NPI: | 1730145533 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AVERILL MOFFITT | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | AVERILL | ||||||||
| OtherFirstName: | JENNIFFER | ||||||||
| OtherMiddleName: | J | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 26 QUEEN ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016102473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088607700 | ||||||||
| FaxNumber: | 5088607929 | ||||||||
| Practice Location | |||||||||
| Address1: | 26 QUEEN ST | ||||||||
| Address2: | FAMILY HEALTH CENTER OF WORCESTER, INC. | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016102473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088607700 | ||||||||
| FaxNumber: | 5088607929 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2006 | ||||||||
| LastUpdateDate: | 09/02/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 176B00000X | 257370 | MA | Y | Other Service Providers | Midwife |
ID Information
| ID | Type | State | Issuer | Description | 1300709 | 05 | MA | MEDICAID | Y10141 | 01 | MEDICARE GROUP # | OTHER | CN0334 | 01 | MA | BLUE SHIELD NUMBER | OTHER |