Provider Demographics
NPI:1982142519
Name:SULLIVAN, JESSICA JEANNE (NP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:JEANNE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:JEANNE
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:55 FOGG RD
Mailing Address - Street 2:
Mailing Address - City:WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02190-2432
Mailing Address - Country:US
Mailing Address - Phone:781-624-8000
Mailing Address - Fax:
Practice Address - Street 1:55 FOGG RD
Practice Address - Street 2:
Practice Address - City:WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-2432
Practice Address - Country:US
Practice Address - Phone:781-624-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-02
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2306549163W00000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse