Provider Demographics
NPI:1538874375
Name:CHAN, JENNIFER W (STUDENT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:W
Last Name:CHAN
Suffix:
Gender:F
Credentials:STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 MARTIN RD
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481-2443
Mailing Address - Country:US
Mailing Address - Phone:617-552-2756
Mailing Address - Fax:
Practice Address - Street 1:140 COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:CHESTNUT HILL
Practice Address - State:MA
Practice Address - Zip Code:02467-3800
Practice Address - Country:US
Practice Address - Phone:617-552-2756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-17
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2295427163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse