Provider Demographics
NPI:1942648639
Name:POWELL, JENNIFER LUO (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LUO
Last Name:POWELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:LUO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:578 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-3900
Mailing Address - Country:US
Mailing Address - Phone:781-321-3422
Mailing Address - Fax:781-321-1863
Practice Address - Street 1:578 MAIN ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-3900
Practice Address - Country:US
Practice Address - Phone:781-321-3422
Practice Address - Fax:781-321-1863
Is Sole Proprietor?:No
Enumeration Date:2013-06-05
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA256152207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine