Provider Demographics
NPI:1609229798
Name:IANNUCCILLI, JENNA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:MARIE
Last Name:IANNUCCILLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 CHALKSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-4728
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 MASSASOIT AVE STE 300
Practice Address - Street 2:
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914-2012
Practice Address - Country:US
Practice Address - Phone:401-434-2704
Practice Address - Fax:401-434-4054
Is Sole Proprietor?:No
Enumeration Date:2016-07-13
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILP03816207R00000X
RIMD16838207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine