Provider Demographics
NPI:1104894005
Name:JACOVONI, MARTHA (NP)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:JACOVONI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 LEONARD ST
Mailing Address - Street 2:SUITE 7
Mailing Address - City:FOXBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02035-2939
Mailing Address - Country:US
Mailing Address - Phone:508-543-2206
Mailing Address - Fax:508-543-2231
Practice Address - Street 1:56 LEONARD ST
Practice Address - Street 2:SUITE 7
Practice Address - City:FOXBORO
Practice Address - State:MA
Practice Address - Zip Code:02035-2939
Practice Address - Country:US
Practice Address - Phone:508-543-2206
Practice Address - Fax:508-543-2231
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA110937363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP1119OtherBLUE CROSS OF MASS
MANP1119OtherBLUE CROSS OF MASS
MAS56267Medicare UPIN