Provider Demographics
NPI:1649883596
Name:PENDERGAST, JASON MACBETH
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:MACBETH
Last Name:PENDERGAST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:439 S UNION ST UNIT 403
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01843-2837
Mailing Address - Country:US
Mailing Address - Phone:866-610-2273
Mailing Address - Fax:617-426-1311
Practice Address - Street 1:439 S UNION ST UNIT 403
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01843-2837
Practice Address - Country:US
Practice Address - Phone:866-610-2273
Practice Address - Fax:617-426-1311
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2290756163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management