Provider Demographics
NPI:1265629968
Name:DOUGHERTY, JENNIFER LYNN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:DOUGHERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:GRIGLIONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:540 N DUKE ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17602-2374
Mailing Address - Country:US
Mailing Address - Phone:717-544-4930
Mailing Address - Fax:717-544-4964
Practice Address - Street 1:540 N DUKE ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-2374
Practice Address - Country:US
Practice Address - Phone:717-544-4930
Practice Address - Fax:717-544-4964
Is Sole Proprietor?:No
Enumeration Date:2007-09-27
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053172363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA119656GFJMedicare PIN