Provider Demographics
NPI:1114095304
Name:PROVENZANO, JAY A (DC)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:A
Last Name:PROVENZANO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:25 SCHOOL ST
Mailing Address - Street 2:SUITE B-2
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-6607
Mailing Address - Country:US
Mailing Address - Phone:617-689-0440
Mailing Address - Fax:617-689-0420
Practice Address - Street 1:25 SCHOOL ST
Practice Address - Street 2:SUITE B-2
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-6607
Practice Address - Country:US
Practice Address - Phone:617-689-0440
Practice Address - Fax:617-689-0420
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA2886111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY4571601Medicare PIN