Provider Demographics
NPI:1396964037
Name:YATES, JENNIFER K
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:K
Last Name:YATES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:33 KENDALL ST
Practice Address - Street 2:DEPARTMENT OF UROLOGY
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2726
Practice Address - Country:US
Practice Address - Phone:508-856-5821
Practice Address - Fax:508-856-3137
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILP00696208800000X
MA254176208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110095125AMedicaid
MA110095125AMedicaid