Provider Demographics
NPI:1619953098
Name:GONDELMAN, JENNIFER (APRN, BC, RNCS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GONDELMAN
Suffix:
Gender:F
Credentials:APRN, BC, RNCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 HIGHLAND ST
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:MA
Mailing Address - Zip Code:02186-4432
Mailing Address - Country:US
Mailing Address - Phone:617-650-2520
Mailing Address - Fax:617-298-2607
Practice Address - Street 1:324 HIGHLAND ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:MA
Practice Address - Zip Code:02186-4432
Practice Address - Country:US
Practice Address - Phone:617-690-2520
Practice Address - Fax:617-298-2607
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2020-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA250606364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
P64169Medicare UPIN
MANS0539Medicare ID - Type Unspecified