Provider Demographics
NPI:1154574986
Name:QUEEN, JENNIE LOUISA (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIE
Middle Name:LOUISA
Last Name:QUEEN
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 1:106 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19709-1439
Mailing Address - Country:US
Mailing Address - Phone:302-449-1710
Mailing Address - Fax:
Practice Address - Street 1:106 S BROAD ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:DE
Practice Address - Zip Code:19709-1439
Practice Address - Country:US
Practice Address - Phone:302-449-1710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-24
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-439363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical