Provider Demographics
NPI:1710056023
Name:WILLIS, JANE D (MD)
Entity Type:Individual
Prefix:MS
First Name:JANE
Middle Name:D
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 372
Mailing Address - Street 2:
Mailing Address - City:ASHFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01330-0372
Mailing Address - Country:US
Mailing Address - Phone:413-834-3145
Mailing Address - Fax:413-691-0478
Practice Address - Street 1:10 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:SHELBURNE FALLS
Practice Address - State:MA
Practice Address - Zip Code:01370-1146
Practice Address - Country:US
Practice Address - Phone:413-834-3145
Practice Address - Fax:413-691-0478
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA221400208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2103702Medicaid
G22851Medicare UPIN
MAA38350Medicare ID - Type Unspecified