Provider Demographics
NPI:1801875380
Name:GILL, JENNIFER M (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:GILL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 MOUNT AUBURN ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-4656
Mailing Address - Country:US
Mailing Address - Phone:617-547-1995
Mailing Address - Fax:
Practice Address - Street 1:575 MOUNT AUBURN ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-4656
Practice Address - Country:US
Practice Address - Phone:617-547-1995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA225336208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2105110Medicaid
MAA38535Medicare ID - Type Unspecified
MA2105110Medicaid