Provider Demographics
NPI:1144210261
Name:BALUKONIS, JENNIFER ROSE (APRN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ROSE
Last Name:BALUKONIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2014 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02462-1699
Mailing Address - Country:US
Mailing Address - Phone:617-243-6144
Mailing Address - Fax:
Practice Address - Street 1:2014 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02462-1607
Practice Address - Country:US
Practice Address - Phone:617-243-6144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH053185-23363L00000X
MA259428363L00000X
MARN259428363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30347938Medicaid
NH001486301Medicare PIN
NH30347938Medicaid