Provider Demographics
NPI:1255667796
Name:RAYMOND, JACLENE
Entity Type:Individual
Prefix:
First Name:JACLENE
Middle Name:
Last Name:RAYMOND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 S RIVER RD STE 101
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03110-6927
Mailing Address - Country:US
Mailing Address - Phone:603-647-0494
Mailing Address - Fax:603-647-0493
Practice Address - Street 1:160 S RIVER RD STE 100
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110
Practice Address - Country:US
Practice Address - Phone:603-647-0494
Practice Address - Fax:603-647-0493
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH062520-21163W00000X
MARN2262268163W00000X
NH062520-23363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No163W00000XNursing Service ProvidersRegistered Nurse