Provider Demographics
NPI:1275664658
Name:STEVENS, JACQUELYN BROOKE (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:BROOKE
Last Name:STEVENS
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 1:109 TRAPELO RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:MA
Mailing Address - Zip Code:01773-2811
Mailing Address - Country:US
Mailing Address - Phone:781-322-3224
Mailing Address - Fax:
Practice Address - Street 1:452 PLEASANT ST
Practice Address - Street 2:OFFICE OF MICHAEL S. WIEDMAN, M.D.
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148
Practice Address - Country:US
Practice Address - Phone:781-322-3224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA158811207R00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine