Provider Demographics
NPI:1063729481
Name:LITTLEDIKE, JENNIFER B (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:B
Last Name:LITTLEDIKE
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 1:210 MILLPOND
Mailing Address - Street 2:
Mailing Address - City:STANSBURY PARK
Mailing Address - State:UT
Mailing Address - Zip Code:84074-8187
Mailing Address - Country:US
Mailing Address - Phone:435-843-3647
Mailing Address - Fax:
Practice Address - Street 1:210 MILLPOND
Practice Address - Street 2:
Practice Address - City:STANSBURY PARK
Practice Address - State:UT
Practice Address - Zip Code:84074-8187
Practice Address - Country:US
Practice Address - Phone:435-843-3647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-07
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical