Provider Demographics
NPI:1225082498
Name:MAUDE, JENNIFER L (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:MAUDE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1358
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02901-1358
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:909 N MAIN ST
Practice Address - Street 2:SUITE 300
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5752
Practice Address - Country:US
Practice Address - Phone:401-273-4064
Practice Address - Fax:401-273-1268
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD10059207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIJM32833Medicaid