Provider Demographics
NPI:1285802298
Name:EVANS, JENNIFER (LIC, AC MA)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:LIC, AC MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1776 MASSACHUSETTS AVE STE 2B
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02140-2852
Mailing Address - Country:US
Mailing Address - Phone:617-960-6699
Mailing Address - Fax:
Practice Address - Street 1:1776 MASSACHUSETTS AVE STE 2B
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02140-2852
Practice Address - Country:US
Practice Address - Phone:617-960-6699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-12
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA382171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist