Provider Demographics
NPI:1952380297
Name:MEDEIROS, JENNIFER (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MEDEIROS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 PLANTATION ST
Mailing Address - Street 2:WOT 12TH FLOOR ATTN PHYSICIAN SERVICES
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605
Mailing Address - Country:US
Mailing Address - Phone:508-368-5529
Mailing Address - Fax:508-368-5530
Practice Address - Street 1:135 GOLD STAR BLVD
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606
Practice Address - Country:US
Practice Address - Phone:508-856-9510
Practice Address - Fax:508-853-1907
Is Sole Proprietor?:No
Enumeration Date:2006-01-14
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16230225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
04 2472266OtherTHREE RIVERS
67906OtherFALLON COMMUNITY HEALTH P
042472266OtherPRIVATE HEALTHCARE SYSTEM
Y68323OtherBLUE CARE ELECT
04 2472266OtherONE HEALTH PLAN
Y68323OtherBLUE SHIELD HMO BLUE
Y69329OtherMEDICARE B
2225131OtherFIRST HEALTH
785960OtherMVP HEALTH CARE
Y68323OtherBLUE SHIELD INDEMNITY
7353622OtherAETNA US HEALTHCARE
785960OtherMVP HEALTH CARE