Provider Demographics
NPI:1134536055
Name:PENNIE, JACQUELYN ELISE (PA)
Entity type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:ELISE
Last Name:PENNIE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:JACQUELYN
Other - Middle Name:ELISE
Other - Last Name:DESJARDINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1 LYONS STREET
Mailing Address - Street 2:ATRIUS HEALTH, INC
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02026
Mailing Address - Country:US
Mailing Address - Phone:617-657-6495
Mailing Address - Fax:
Practice Address - Street 1:1 LYONS ST
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-5599
Practice Address - Country:US
Practice Address - Phone:508-880-0012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-14
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA5064363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant