Provider Demographics
NPI:1205594579
Name:SELLY, JOSHUA JACKSON (NP)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:JACKSON
Last Name:SELLY
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 PLANTATION ST APT 627
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01604-7715
Mailing Address - Country:US
Mailing Address - Phone:508-736-3326
Mailing Address - Fax:
Practice Address - Street 1:285 PLANTATION ST APT 627
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604-7715
Practice Address - Country:US
Practice Address - Phone:508-736-3326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-03
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2303725363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health