Provider Demographics
NPI:1821077314
Name:WOLF, JACQUELINE LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:LEE
Last Name:WOLF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 BROOKLINE AVE RABB 437
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5400
Mailing Address - Country:US
Mailing Address - Phone:617-667-4241
Mailing Address - Fax:617-667-5624
Practice Address - Street 1:330 BROOKLINE AVE # RABB437
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5400
Practice Address - Country:US
Practice Address - Phone:617-667-4241
Practice Address - Fax:617-667-5624
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA43011207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0107999Medicaid
MAE05245Medicare ID - Type Unspecified
MA0107999Medicaid