Provider Demographics
NPI:1407393010
Name:JOB, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:JOB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 LINCOLN ST STE 6
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2430
Mailing Address - Country:US
Mailing Address - Phone:774-530-6955
Mailing Address - Fax:774-530-6956
Practice Address - Street 1:130 LINCOLN ST STE 6
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2430
Practice Address - Country:US
Practice Address - Phone:774-530-6955
Practice Address - Fax:774-530-6956
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-21
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2271934363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health