Provider Demographics
NPI:1083274765
Name:LOCKE, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LOCKE
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 1:48 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:MA
Mailing Address - Zip Code:01562-1621
Mailing Address - Country:US
Mailing Address - Phone:774-272-2304
Mailing Address - Fax:
Practice Address - Street 1:198 CHARLTON RD
Practice Address - Street 2:
Practice Address - City:STURBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01566-1571
Practice Address - Country:US
Practice Address - Phone:508-347-7585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-16
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2293248363LF0000X
MARN2293248363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily