Provider Demographics
NPI:1093057580
Name:MASSARELLI, JENNIFER (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:MASSARELLI
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:55 LAKE AVE N
Mailing Address - Street 2:UMASS MEMORIAL MEDICAL CENTER, PSYCHIATRY
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01655-0002
Mailing Address - Country:US
Mailing Address - Phone:508-334-3562
Mailing Address - Fax:508-421-1000
Practice Address - Street 1:2215 FULLER RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-2303
Practice Address - Country:US
Practice Address - Phone:734-769-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-22
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA276298163WP0808X
MARN276298363LP0808X
MI4704344082363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA276298OtherLICENSE
MI4704344082OtherLICENSE