Provider Demographics
NPI:1427349711
Name:PITMAN, JENNA BRIANDA (PA)
Entity type:Individual
Prefix:MISS
First Name:JENNA
Middle Name:BRIANDA
Last Name:PITMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:JEN
Other - Middle Name:B
Other - Last Name:TOLTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:500 S 11TH AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4880
Mailing Address - Country:US
Mailing Address - Phone:208-232-7862
Mailing Address - Fax:208-232-2408
Practice Address - Street 1:75 YELLOW CREEK RD STE 102
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-5205
Practice Address - Country:US
Practice Address - Phone:307-789-8290
Practice Address - Fax:307-789-8975
Is Sole Proprietor?:No
Enumeration Date:2011-04-21
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1097238363A00000X
WYWY-PA714363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant