Basic Information
Provider Information | |||||||||
NPI: | 1093057580 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MASSARELLI | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NURSE PRACTITIONER | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HALL | ||||||||
OtherFirstName: | JENNIFER | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 55 LAKE AVE N | ||||||||
Address2: | UMASS MEMORIAL MEDICAL CENTER, PSYCHIATRY | ||||||||
City: | WORCESTER | ||||||||
State: | MA | ||||||||
PostalCode: | 016550002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5083343562 | ||||||||
FaxNumber: | 5084211000 | ||||||||
Practice Location | |||||||||
Address1: | 2215 FULLER RD | ||||||||
Address2: |   | ||||||||
City: | ANN ARBOR | ||||||||
State: | MI | ||||||||
PostalCode: | 481052303 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7347697100 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/22/2013 | ||||||||
LastUpdateDate: | 10/25/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/25/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 276298 | MA | N |   | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 363LP0808X | RN276298 | MA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | 4704344082 | MI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
ID | Type | State | Issuer | Description | 276298 | 01 | MA | LICENSE | OTHER | 4704344082 | 01 | MI | LICENSE | OTHER |