Provider Demographics
NPI:1770191959
Name:FENNELL, JACLYN L (RN, AGNP-C)
Entity Type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:L
Last Name:FENNELL
Suffix:
Gender:F
Credentials:RN, AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 HAWSER LN
Mailing Address - Street 2:
Mailing Address - City:SWAMPSCOTT
Mailing Address - State:MA
Mailing Address - Zip Code:01907-1238
Mailing Address - Country:US
Mailing Address - Phone:508-320-8819
Mailing Address - Fax:
Practice Address - Street 1:100 MCGREGOR ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03102-3730
Practice Address - Country:US
Practice Address - Phone:603-663-5310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-14
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2288964363LA2200X
NH092675-23363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health