Provider Demographics
NPI:1912202631
Name:KHALED, JENNIFER ELIZEBETH (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELIZEBETH
Last Name:KHALED
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 1:41541 CARTHAGE RD
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:NE
Mailing Address - Zip Code:68869-4073
Mailing Address - Country:US
Mailing Address - Phone:531-218-4184
Mailing Address - Fax:
Practice Address - Street 1:41541 CARTHAGE RD
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:NE
Practice Address - Zip Code:68869-4073
Practice Address - Country:US
Practice Address - Phone:531-218-4184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-12
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NY02750363AM0700X
NE1818363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant