Provider Demographics
NPI:1730145533
Name:AVERILL MOFFITT, JENNIFER J (CNM)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:J
Last Name:AVERILL MOFFITT
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:JENNIFFER
Other - Middle Name:J
Other - Last Name:AVERILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:26 QUEEN ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01610-2473
Mailing Address - Country:US
Mailing Address - Phone:508-860-7700
Mailing Address - Fax:508-860-7929
Practice Address - Street 1:26 QUEEN ST
Practice Address - Street 2:FAMILY HEALTH CENTER OF WORCESTER, INC.
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610-2473
Practice Address - Country:US
Practice Address - Phone:508-860-7700
Practice Address - Fax:508-860-7929
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA257370176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1300709Medicaid
Y10141OtherMEDICARE GROUP #
MACN0334OtherBLUE SHIELD NUMBER