Provider Demographics
NPI:1104241678
Name:LUCAS, JENNIFER FOWLER (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:FOWLER
Last Name:LUCAS
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:PO BOX 159
Mailing Address - Street 2:
Mailing Address - City:ONLEY
Mailing Address - State:VA
Mailing Address - Zip Code:23418-0159
Mailing Address - Country:US
Mailing Address - Phone:757-787-7374
Mailing Address - Fax:
Practice Address - Street 1:20306 BADGER LANE
Practice Address - Street 2:
Practice Address - City:ONLEY
Practice Address - State:VA
Practice Address - Zip Code:23418-0159
Practice Address - Country:US
Practice Address - Phone:757-787-7374
Practice Address - Fax:757-787-4513
Is Sole Proprietor?:No
Enumeration Date:2014-02-20
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004450363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical