Provider Demographics
NPI:1336831643
Name:MARENA, JILLIAN GRACE (PA-C)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:GRACE
Last Name:MARENA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 CLIFTON ST
Mailing Address - Street 2:
Mailing Address - City:OLD LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06371-2413
Mailing Address - Country:US
Mailing Address - Phone:860-371-1526
Mailing Address - Fax:
Practice Address - Street 1:1 BOSTON MEDICAL CTR PL STE 1
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2999
Practice Address - Country:US
Practice Address - Phone:617-638-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-24
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA9531363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant