Provider Demographics
NPI:1316689078
Name:VICENTE, JACOB (DNP, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:VICENTE
Suffix:
Gender:
Credentials:DNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 PARKINGWAY
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-5029
Mailing Address - Country:US
Mailing Address - Phone:618-328-1189
Mailing Address - Fax:
Practice Address - Street 1:411 WAVERLY OAKS RD
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02452-8448
Practice Address - Country:US
Practice Address - Phone:978-732-8458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-12
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2309147163WH0500X, 363LP0808X
CT14685363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WH0500XNursing Service ProvidersRegistered NurseHemodialysis