Provider Demographics
NPI:1427056621
Name:GODDARD BRANT, JENNIFER (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GODDARD BRANT
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 1:300 DORCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21613-2420
Mailing Address - Country:US
Mailing Address - Phone:410-228-2603
Mailing Address - Fax:410-901-6080
Practice Address - Street 1:300 DORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21613-2420
Practice Address - Country:US
Practice Address - Phone:410-228-2603
Practice Address - Fax:410-901-6080
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0000549363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD242M323FMedicare PIN
MDS52745Medicare UPIN