Provider Demographics
NPI:1104242916
Name:REILLY, JENNIFER THRASHER (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:THRASHER
Last Name:REILLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:KRISTIN
Other - Last Name:THRASHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:110 KNIGHTS BRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:MAYS LANDING
Mailing Address - State:NJ
Mailing Address - Zip Code:08330-2051
Mailing Address - Country:US
Mailing Address - Phone:850-814-8611
Mailing Address - Fax:
Practice Address - Street 1:2500 ENGLISH CREEK AVE
Practice Address - Street 2:
Practice Address - City:EGG HARBOR TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08234-5549
Practice Address - Country:US
Practice Address - Phone:609-407-2332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-17
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00330200363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MP00330200OtherNJ BOARD OF MEDICAL EXAMINERS- PHYSICIAN ASSISTANT LICENSE