Provider Demographics
NPI:1952372559
Name:DEVINE, JENNIFER M
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:DEVINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:M
Other - Last Name:BAILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 391
Mailing Address - Street 2:INNOVATIVE PHYSICIAN SERVICES LLC
Mailing Address - City:WILBRAHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01095-0391
Mailing Address - Country:US
Mailing Address - Phone:508-595-0531
Mailing Address - Fax:508-829-5367
Practice Address - Street 1:14 CHESTNUT PLACE
Practice Address - Street 2:
Practice Address - City:LUDLOW
Practice Address - State:MA
Practice Address - Zip Code:01056
Practice Address - Country:US
Practice Address - Phone:413-589-7581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA1861363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAP2286Medicare ID - Type Unspecified
Q29158Medicare UPIN