Provider Demographics
NPI:1962515213
Name:KALATA, JENNIFER L (PA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:KALATA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:KALATA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:2911 TENNYSON AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97408-4393
Mailing Address - Country:US
Mailing Address - Phone:541-844-1495
Mailing Address - Fax:541-844-1492
Practice Address - Street 1:2911 TENNYSON AVE STE 201
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97408
Practice Address - Country:US
Practice Address - Phone:541-844-1495
Practice Address - Fax:541-844-1492
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA176991363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001019016Medicaid
PA116107Medicare PIN