Provider Demographics
NPI:1689703720
Name:BERRY, JENNIFER JAEN (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JAEN
Last Name:BERRY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:HORLANDA
Other - Last Name:JAEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:415 NEPONSET AVE
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02122-3168
Mailing Address - Country:US
Mailing Address - Phone:774-218-5585
Mailing Address - Fax:
Practice Address - Street 1:101 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609-3213
Practice Address - Country:US
Practice Address - Phone:508-798-2225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11009225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0396753Medicaid
MA0396753Medicaid