Provider Demographics
NPI:1033104328
Name:REILLY, JACQUELYN (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:REILLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:REILLY
Other - Last Name:KANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:100 WASON AVENUE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01107
Mailing Address - Country:US
Mailing Address - Phone:413-732-7426
Mailing Address - Fax:413-734-2371
Practice Address - Street 1:100 WASON AVENUE
Practice Address - Street 2:SUITE 110
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107
Practice Address - Country:US
Practice Address - Phone:413-732-7426
Practice Address - Fax:413-734-2371
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA217113207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2018675Medicaid
H91180Medicare UPIN
A35840Medicare ID - Type Unspecified