Provider Demographics
NPI:1093364051
Name:MARSHALL, JENNA LEA (PA)
Entity Type:Individual
Prefix:MRS
First Name:JENNA
Middle Name:LEA
Last Name:MARSHALL
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 1:145 CLOVERBANK RD
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-9360
Mailing Address - Country:US
Mailing Address - Phone:352-224-8951
Mailing Address - Fax:
Practice Address - Street 1:13241 BARTRAM PARK BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-5212
Practice Address - Country:US
Practice Address - Phone:904-402-8346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-11
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant