Provider Demographics
NPI:1447240890
Name:JANTZEN, KATHERINE A (APRN, BC)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:A
Last Name:JANTZEN
Suffix:
Gender:F
Credentials:APRN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 CITY VIEW RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-2239
Mailing Address - Country:US
Mailing Address - Phone:617-277-9186
Mailing Address - Fax:
Practice Address - Street 1:2 DUNDEE PARK DR
Practice Address - Street 2:SUITE #303
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-3735
Practice Address - Country:US
Practice Address - Phone:978-475-6950
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA141135364SP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS46908Medicare UPIN
MAJA NS0053Medicare ID - Type Unspecified