Provider Demographics
NPI:1679904346
Name:RAYMOND, JACKIE (RN)
Entity type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:
Last Name:RAYMOND
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 NEW LANCASTER RD
Mailing Address - Street 2:
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453-4958
Mailing Address - Country:US
Mailing Address - Phone:978-466-3208
Mailing Address - Fax:978-840-1680
Practice Address - Street 1:225 NEW LANCASTER RD
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-4958
Practice Address - Country:US
Practice Address - Phone:978-466-3208
Practice Address - Fax:978-840-1680
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-06
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2289192363LF0000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110110032AMedicaid