Provider Demographics
NPI:1508947748
Name:LO, JENNIFER JOSE' (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:JOSE'
Last Name:LO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:CARMEN
Other - Last Name:JOSE'
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:780 ALBANY ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2524
Mailing Address - Country:US
Mailing Address - Phone:857-654-1000
Mailing Address - Fax:857-654-1100
Practice Address - Street 1:780 ALBANY ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2524
Practice Address - Country:US
Practice Address - Phone:857-654-1000
Practice Address - Fax:857-654-1100
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA246754207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HII12208Medicare UPIN