Provider Demographics
NPI:1699032128
Name:RUSSO, JENNIFER (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:ABORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:37 FRIEND ST
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01902-3068
Mailing Address - Country:US
Mailing Address - Phone:978-513-7300
Mailing Address - Fax:781-268-5070
Practice Address - Street 1:166 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852
Practice Address - Country:US
Practice Address - Phone:978-513-7300
Practice Address - Fax:781-268-5070
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-22
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA261536207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine