Provider Demographics
NPI:1699767384
Name:RICHARDSON, JENNIFER LYNN (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:RICHARDSON
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 1:4511 N DAVIS HWY # C-1
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2720
Mailing Address - Country:US
Mailing Address - Phone:850-477-3252
Mailing Address - Fax:850-477-2659
Practice Address - Street 1:4511 N DAVIS HWY
Practice Address - Street 2:SUITE C-1
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2734
Practice Address - Country:US
Practice Address - Phone:850-477-3252
Practice Address - Fax:850-477-2659
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101066363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS97546Medicare UPIN
FLE3537ZMedicare ID - Type Unspecified