Provider Demographics
NPI:1457805194
Name:FARESE, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:FARESE
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 1:24 JOAN RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-1512
Mailing Address - Country:US
Mailing Address - Phone:603-401-4961
Mailing Address - Fax:
Practice Address - Street 1:41 MALL ROAD
Practice Address - Street 2:LAHEY HOSPITAL AND MEDICAL CENTER
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01805
Practice Address - Country:US
Practice Address - Phone:781-744-3839
Practice Address - Fax:781-744-1597
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-11
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant