Provider Demographics
NPI:1023386984
Name:ROGERS, JENNIFER ASHLEY (PAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ASHLEY
Last Name:ROGERS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1222 S ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1215
Mailing Address - Country:US
Mailing Address - Phone:321-841-3050
Mailing Address - Fax:321-841-3049
Practice Address - Street 1:1222 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1215
Practice Address - Country:US
Practice Address - Phone:321-841-3050
Practice Address - Fax:321-841-3049
Is Sole Proprietor?:No
Enumeration Date:2011-12-07
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106236363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004158000Medicaid
FLPA9106236OtherMEDICAL LICENSE
FLPA9106236OtherMEDICAL LICENSE