Provider Demographics
NPI:1649797663
Name:DONNELLAN BALLARD, JARED JOSEPH
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:JOSEPH
Last Name:DONNELLAN BALLARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:293 WASHINGTON ST REAR
Mailing Address - Street 2:
Mailing Address - City:NORWELL
Mailing Address - State:MA
Mailing Address - Zip Code:02061-1781
Mailing Address - Country:US
Mailing Address - Phone:617-588-0102
Mailing Address - Fax:
Practice Address - Street 1:293 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NORWELL
Practice Address - State:MA
Practice Address - Zip Code:02061-1781
Practice Address - Country:US
Practice Address - Phone:617-588-0102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2304514363LP0808X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse