Provider Demographics
NPI:1083797302
Name:TIPPETT, JODI LYNN (APRN BC)
Entity Type:Individual
Prefix:MS
First Name:JODI
Middle Name:LYNN
Last Name:TIPPETT
Suffix:
Gender:F
Credentials:APRN BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 ELM ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-5356
Mailing Address - Country:US
Mailing Address - Phone:781-894-8440
Mailing Address - Fax:781-894-1202
Practice Address - Street 1:169 ELM ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-5356
Practice Address - Country:US
Practice Address - Phone:781-894-8440
Practice Address - Fax:781-894-1202
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA237497363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1303287OtherMBHP
MA1303287Medicaid
MAM18633OtherBCBS
MA1303287Medicaid
MAY10074Medicare ID - Type Unspecified