Provider Demographics
NPI:1659617207
Name:MODLISZEWSKI, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MODLISZEWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 CAMBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-4302
Mailing Address - Country:US
Mailing Address - Phone:931-980-2555
Mailing Address - Fax:
Practice Address - Street 1:1611 CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-4302
Practice Address - Country:US
Practice Address - Phone:617-661-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-28
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2274129363LA2200X
MA2274129163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WH0200XNursing Service ProvidersRegistered NurseHome Health