Provider Demographics
NPI:1083687024
Name:HENRY, JARROD JOHN (PA-C)
Entity Type:Individual
Prefix:
First Name:JARROD
Middle Name:JOHN
Last Name:HENRY
Suffix:
Gender:M
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 1:12 SHUMAN AVE
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-6020
Mailing Address - Country:US
Mailing Address - Phone:207-622-8600
Mailing Address - Fax:207-622-8601
Practice Address - Street 1:12 SHUMAN AVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-6020
Practice Address - Country:US
Practice Address - Phone:207-622-8600
Practice Address - Fax:207-622-8601
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA1334363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
838363OtherMEDICARE GROUP ASSIGN
P00320656OtherMEDICARE RAILROAD
838363OtherBS GROUP ASSIGN
838363OtherBS GROUP ASSIGN
001811207OtherSECURITY BLUE