Provider Demographics
NPI:1093115115
Name:JAGELSKI, MARY ELLEN
Entity Type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:JAGELSKI
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 1:15 CHILTON RD
Mailing Address - Street 2:
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-1717
Mailing Address - Country:US
Mailing Address - Phone:617-325-3215
Mailing Address - Fax:
Practice Address - Street 1:15 CHILTON RD
Practice Address - Street 2:
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132-1717
Practice Address - Country:US
Practice Address - Phone:617-325-3215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-26
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA127565363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health