Provider Demographics
NPI:1437918653
Name:THERIAULT, JENNIFER A (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:THERIAULT
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 PHILLIPS ST
Mailing Address - Street 2:
Mailing Address - City:HANSON
Mailing Address - State:MA
Mailing Address - Zip Code:02341-1519
Mailing Address - Country:US
Mailing Address - Phone:617-688-1022
Mailing Address - Fax:
Practice Address - Street 1:160 OLD DERBY ST STE 110
Practice Address - Street 2:
Practice Address - City:HINGHAM
Practice Address - State:MA
Practice Address - Zip Code:02043-4010
Practice Address - Country:US
Practice Address - Phone:617-688-1022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-18
Last Update Date:2024-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN231982363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health