Provider Demographics
NPI:1174597165
Name:MASSARA, JENNIFER LYNN (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:MASSARA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:ROCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:705 ELM ST SW STE 200
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-1957
Mailing Address - Country:US
Mailing Address - Phone:541-812-4850
Mailing Address - Fax:
Practice Address - Street 1:705 ELM ST SW
Practice Address - Street 2:SUITE 200
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321
Practice Address - Country:US
Practice Address - Phone:541-812-4850
Practice Address - Fax:541-812-4889
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD151178207V00000X
WAMD61120008207V00000X
AZ35721207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ35721OtherAZ MEDICAL BOARD
AZ150211Medicaid