Provider Demographics
NPI:1306148986
Name:HALLETT, JENNIFER M (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:HALLETT
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 1:92 CAMPUS DR STE D
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-7229
Mailing Address - Country:US
Mailing Address - Phone:207-662-8900
Mailing Address - Fax:
Practice Address - Street 1:92 CAMPUS DR STE D
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-7229
Practice Address - Country:US
Practice Address - Phone:207-662-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-02
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA001227363A00000X
FLPA9108723363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIL833ZMedicare PIN