Provider Demographics
NPI:1417042870
Name:ZIMMERMAN, JENNIFER LEE (PA-C)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LEE
Last Name:ZIMMERMAN
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 1:1441 FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4404
Mailing Address - Country:US
Mailing Address - Phone:209-576-3601
Mailing Address - Fax:209-576-3680
Practice Address - Street 1:1441 FLORIDA AVE.
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95352
Practice Address - Country:US
Practice Address - Phone:209-578-1211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA10924363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACD069AOtherGROUP PTAN-GREATER MODESTO MEDICAL SURGICAL ASSOCIATES
CACD069AOtherGROUP PTAN-GREATER MODESTO MEDICAL SURGICAL ASSOCIATES