Provider Demographics
NPI:1326475633
Name:JENIKE, LISA R (NP)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:R
Last Name:JENIKE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 CHESTNUT ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01199-1001
Mailing Address - Country:US
Mailing Address - Phone:413-794-5700
Mailing Address - Fax:
Practice Address - Street 1:50 WASON AVENUE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1274
Practice Address - Country:US
Practice Address - Phone:413-794-5437
Practice Address - Fax:413-794-4018
Is Sole Proprietor?:No
Enumeration Date:2013-10-01
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN260828363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily