Provider Demographics
NPI:1508009028
Name:PROUTY, JENNIFER L (CNS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:PROUTY
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 COUNTY RD
Mailing Address - Street 2:POST OFFICE BOX 1006
Mailing Address - City:MATTAPOISETT
Mailing Address - State:MA
Mailing Address - Zip Code:02739-1650
Mailing Address - Country:US
Mailing Address - Phone:508-758-6898
Mailing Address - Fax:508-758-6397
Practice Address - Street 1:74 COUNTY RD
Practice Address - Street 2:POST OFFICE BOX 1006
Practice Address - City:MATTAPOISETT
Practice Address - State:MA
Practice Address - Zip Code:02739-1650
Practice Address - Country:US
Practice Address - Phone:508-758-6898
Practice Address - Fax:508-758-6397
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-14
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA127636364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult