Provider Demographics
NPI:1316216492
Name:PENNINGTON ORTEGA, JACLYN MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:MARIE
Last Name:PENNINGTON ORTEGA
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 1:4601 E LAKELAND DR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32404-5219
Mailing Address - Country:US
Mailing Address - Phone:850-625-0562
Mailing Address - Fax:
Practice Address - Street 1:204 E 19TH ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4707
Practice Address - Country:US
Practice Address - Phone:850-763-5409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-20
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9105851363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant