Provider Demographics
NPI:1215148606
Name:DISTASIO, JENNA CHRISTINA (PA)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:CHRISTINA
Last Name:DISTASIO
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Gender:F
Credentials:PA
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Mailing Address - Street 1:20 GUEST ST
Mailing Address - Street 2:STE 225
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-2065
Mailing Address - Country:US
Mailing Address - Phone:617-738-8642
Mailing Address - Fax:617-202-4172
Practice Address - Street 1:91 PARKER HILL AVE
Practice Address - Street 2:
Practice Address - City:ROXBURY CROSSING
Practice Address - State:MA
Practice Address - Zip Code:02120-3215
Practice Address - Country:US
Practice Address - Phone:617-754-6742
Practice Address - Fax:617-754-6443
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2020-08-19
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Provider Licenses
StateLicense IDTaxonomies
MA2229363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant