Provider Demographics
NPI:1922261353
Name:STAFFORD, JENSY PULIKAMALIL (MD)
Entity Type:Individual
Prefix:
First Name:JENSY
Middle Name:PULIKAMALIL
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENSY
Other - Middle Name:PULIKAMALIL
Other - Last Name:JACOB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1085 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-5719
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1085 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5719
Practice Address - Country:US
Practice Address - Phone:401-415-4242
Practice Address - Fax:401-312-2356
Is Sole Proprietor?:No
Enumeration Date:2008-07-07
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA246929207Q00000X
RI13939207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine