Provider Demographics
NPI:1225012586
Name:CIVITELLA, JENNIFER ANN (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:CIVITELLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNY
Other - Middle Name:
Other - Last Name:MCCALLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:454 OLD STREET RD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:PETERBOROUGH
Mailing Address - State:NH
Mailing Address - Zip Code:03458-1200
Mailing Address - Country:US
Mailing Address - Phone:603-924-4664
Mailing Address - Fax:603-924-8653
Practice Address - Street 1:454 OLD STREET RD
Practice Address - Street 2:SUITE 207
Practice Address - City:PETERBOROUGH
Practice Address - State:NH
Practice Address - Zip Code:03458-1200
Practice Address - Country:US
Practice Address - Phone:603-924-4664
Practice Address - Fax:603-924-8653
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH12233207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30204083Medicaid
NH30204083Medicaid
G37963Medicare UPIN