Provider Demographics
NPI:1013549310
Name:MORGAN, JENNA R
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:R
Last Name:MORGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 COMMONWEALTH AVE APT 24
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-6026
Mailing Address - Country:US
Mailing Address - Phone:617-462-4789
Mailing Address - Fax:
Practice Address - Street 1:415 NEPONSET AVE STE 3
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-3169
Practice Address - Country:US
Practice Address - Phone:857-217-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA983352712OtherBLUE CROSS