Provider Demographics
NPI:1154873008
Name:GRACE, JENNIFER (OD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:GRACE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:PHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:45 DEPOT ST UNIT 45C
Mailing Address - Street 2:
Mailing Address - City:DUXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02332-4431
Mailing Address - Country:US
Mailing Address - Phone:339-217-2985
Mailing Address - Fax:339-217-2986
Practice Address - Street 1:45 DEPOT ST UNIT 45C
Practice Address - Street 2:
Practice Address - City:DUXBURY
Practice Address - State:MA
Practice Address - Zip Code:02332-4431
Practice Address - Country:US
Practice Address - Phone:339-217-2985
Practice Address - Fax:339-217-2986
Is Sole Proprietor?:No
Enumeration Date:2016-10-26
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5192152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA120161202000158Medicaid
MA1154873008Medicaid