Provider Demographics
NPI:1801257746
Name:ANDERSON, JENNELLE (CNP)
Entity type:Individual
Prefix:
First Name:JENNELLE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:326 NICHOLS RD
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420-1914
Mailing Address - Country:US
Mailing Address - Phone:978-878-8100
Mailing Address - Fax:
Practice Address - Street 1:326 NICHOLS RD
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-1914
Practice Address - Country:US
Practice Address - Phone:978-878-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-18
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2298593163WC1500X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1303007Medicaid