Provider Demographics
NPI:1801952569
Name:PENTHENY, JANE
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:PENTHENY
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 1:147 MILK ST
Mailing Address - Street 2:PROVIDER ENROLLMENT - 9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-421-2508
Mailing Address - Fax:
Practice Address - Street 1:111 GROSSMAN DR
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-4997
Practice Address - Country:US
Practice Address - Phone:781-849-2295
Practice Address - Fax:781-849-2514
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3362152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0014540OtherNHP
MA9390295-002OtherCIGNA
MA003362OtherTUFTS
MA0393711Medicaid
MAE199OtherHPHC
MAT31376Medicare UPIN
MA0014540OtherNHP