Provider Demographics
NPI:1033143128
Name:KICKHAM, JENNIFER MOORE (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MOORE
Last Name:KICKHAM
Suffix:
Gender:F
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-6850
Mailing Address - Fax:617-724-5843
Practice Address - Street 1:55 FRUIT STREET YAW 4
Practice Address - Street 2:VINCENT OB/GYN SERVICE
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:617-724-6850
Practice Address - Fax:617-724-5843
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2012-11-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA215787207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0178861Medicaid
MAJ25357OtherBCBS MA
MA215787OtherTUFTS HEALTH PLAN
MA0178861Medicaid
MAJ25357OtherBCBS MA