Provider Demographics
NPI:1225006398
Name:MACK, JENNIFER WILLIAMS (MD MPH)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:WILLIAMS
Last Name:MACK
Suffix:
Gender:F
Credentials:MD MPH
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LEE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:450 BROOKLINE AVE
Mailing Address - Street 2:DANA 11
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5418
Mailing Address - Country:US
Mailing Address - Phone:617-632-6818
Mailing Address - Fax:617-632-2270
Practice Address - Street 1:44 BINNEY ST
Practice Address - Street 2:454 SUITE 21
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115
Practice Address - Country:US
Practice Address - Phone:617-632-6818
Practice Address - Fax:617-632-2270
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2125292080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ27212OtherBLUE CROSS BLUE SHIELD
AA11960OtherHPHC
212529OtherTUFTS
MA2036436Medicaid
MA2036436Medicaid
A36517Medicare ID - Type Unspecified