Provider Demographics
NPI:1033143268
Name:STEPHANY, JACQUELINE (PA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:STEPHANY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-7539
Mailing Address - Country:US
Mailing Address - Phone:603-225-7000
Mailing Address - Fax:603-230-7218
Practice Address - Street 1:250 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-7539
Practice Address - Country:US
Practice Address - Phone:603-225-7000
Practice Address - Fax:603-230-7218
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0106363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30334020Medicaid
NH30334020Medicaid