Provider Demographics
NPI:1306605159
Name:OCONNELL, JENNIFER (LMT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:OCONNELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 MAIN ST STE 104
Mailing Address - Street 2:
Mailing Address - City:BLACKSTONE
Mailing Address - State:MA
Mailing Address - Zip Code:01504-2215
Mailing Address - Country:US
Mailing Address - Phone:508-918-5055
Mailing Address - Fax:
Practice Address - Street 1:61 MAIN ST STE 104
Practice Address - Street 2:
Practice Address - City:BLACKSTONE
Practice Address - State:MA
Practice Address - Zip Code:01504-2215
Practice Address - Country:US
Practice Address - Phone:508-918-5055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-14
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA17365225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty