Provider Demographics
NPI:1407417991
Name:AUDI, JACKIE (NP)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:AUDI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 ACCESS ROAD
Mailing Address - Street 2:UNIT 24
Mailing Address - City:NORWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02062
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11 RIVER ST
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-2098
Practice Address - Country:US
Practice Address - Phone:781-431-1177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2320561363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health