Provider Demographics
NPI:1275851362
Name:GUSTAFSON, JENA B (PA-C)
Entity Type:Individual
Prefix:
First Name:JENA
Middle Name:B
Last Name:GUSTAFSON
Suffix:
Gender:F
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 1:4308 BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44505-1052
Mailing Address - Country:US
Mailing Address - Phone:330-759-7038
Mailing Address - Fax:330-759-7071
Practice Address - Street 1:4308 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44505-1052
Practice Address - Country:US
Practice Address - Phone:330-759-7038
Practice Address - Fax:330-759-7071
Is Sole Proprietor?:No
Enumeration Date:2010-05-13
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH003058363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant