Provider Demographics
NPI:1184265381
Name:POWERS, JAMIE L
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:L
Last Name:POWERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:L
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:149 GREENWOOD ST
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01880-4070
Mailing Address - Country:US
Mailing Address - Phone:781-540-1560
Mailing Address - Fax:
Practice Address - Street 1:3 WOODLAND RD STE 322
Practice Address - Street 2:
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-1713
Practice Address - Country:US
Practice Address - Phone:781-523-5094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-30
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2321546163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110157824AMedicaid