Provider Demographics
NPI:1427225929
Name:JACKMIN, MARY LANE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LANE
Last Name:JACKMIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:HENRIETTE
Other - Last Name:LANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:333 LONGWOOD AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5711
Mailing Address - Country:US
Mailing Address - Phone:617-355-0648
Mailing Address - Fax:617-730-0337
Practice Address - Street 1:333 LONGWOOD AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5711
Practice Address - Country:US
Practice Address - Phone:617-355-0648
Practice Address - Fax:617-730-0337
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2416363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant