Provider Demographics
NPI:1225136161
Name:ABBOTT, JENIFER (PA-C)
Entity type:Individual
Prefix:
First Name:JENIFER
Middle Name:
Last Name:ABBOTT
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 1:930 REVOLUTION ST
Mailing Address - Street 2:
Mailing Address - City:HAVRE DE GRACE
Mailing Address - State:MD
Mailing Address - Zip Code:21078-3718
Mailing Address - Country:US
Mailing Address - Phone:410-939-0961
Mailing Address - Fax:410-939-7832
Practice Address - Street 1:930 REVOLUTION ST
Practice Address - Street 2:
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078
Practice Address - Country:US
Practice Address - Phone:410-939-0961
Practice Address - Fax:410-939-7832
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
MDC03395363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKL92O821Medicare PIN