Provider Demographics
NPI:1386832681
Name:FORBES, JENNIFER LYNN (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:FORBES
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 1:1141 N ROAD ST
Mailing Address - Street 2:SUITE G
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-3354
Mailing Address - Country:US
Mailing Address - Phone:252-335-5424
Mailing Address - Fax:252-335-1077
Practice Address - Street 1:1141 N ROAD ST
Practice Address - Street 2:SUITE G
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-3354
Practice Address - Country:US
Practice Address - Phone:252-335-5424
Practice Address - Fax:252-335-1077
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL470363A00000X
NC001001368363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51544933OtherBCBS
MS05309207Medicaid
FL292931700Medicaid
AL009913146Medicaid
AL009913146Medicaid