Provider Demographics
NPI:1487125340
Name:PEDERSON, JENNIFER M (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:PEDERSON
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 1:1761 LOUIS PL
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52245-1582
Mailing Address - Country:US
Mailing Address - Phone:319-939-7731
Mailing Address - Fax:
Practice Address - Street 1:2700 QUARRY LAKE DR STE 300
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-3746
Practice Address - Country:US
Practice Address - Phone:410-377-8900
Practice Address - Fax:410-377-0576
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2020-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC07166363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant