Basic Information
| Provider Information | |||||||||
| NPI: | 1215148606 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DISTASIO | ||||||||
| FirstName: | JENNA | ||||||||
| MiddleName: | CHRISTINA | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 GUEST ST | ||||||||
| Address2: | STE 225 | ||||||||
| City: | BRIGHTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021352065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177388642 | ||||||||
| FaxNumber: | 6172024172 | ||||||||
| Practice Location | |||||||||
| Address1: | 91 PARKER HILL AVE | ||||||||
| Address2: | |||||||||
| City: | ROXBURY CROSSING | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021203215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177546742 | ||||||||
| FaxNumber: | 6177546443 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2007 | ||||||||
| LastUpdateDate: | 08/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2229 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.