Provider Demographics
NPI:1952435851
Name:LANE, JENNIFER MICHELE (INTERN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MICHELE
Last Name:LANE
Suffix:
Gender:F
Credentials:INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 PLYMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:MA
Mailing Address - Zip Code:02359-3521
Mailing Address - Country:US
Mailing Address - Phone:781-293-3964
Mailing Address - Fax:
Practice Address - Street 1:70 MAIN ST
Practice Address - Street 2:
Practice Address - City:TAUNTON
Practice Address - State:MA
Practice Address - Zip Code:02780-2778
Practice Address - Country:US
Practice Address - Phone:508-821-7777
Practice Address - Fax:508-822-2601
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1309161Medicaid