Provider Demographics
NPI:1790379972
Name:ROBERTS, JACQUELYN (MSN, APRN, FNP-C,)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-C,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 MITCHELL AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-1736
Mailing Address - Country:US
Mailing Address - Phone:978-808-4757
Mailing Address - Fax:
Practice Address - Street 1:11 SALEM ST STE 15
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-3262
Practice Address - Country:US
Practice Address - Phone:617-299-0440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-27
Last Update Date:2021-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2310867363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner