Provider Demographics
NPI:1417245739
Name:ADDINGTON, JENNIFER R (PAC)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:R
Last Name:ADDINGTON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1387 FOREST ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-1811
Mailing Address - Country:US
Mailing Address - Phone:651-235-5278
Mailing Address - Fax:
Practice Address - Street 1:1400 N ACRES RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:WI
Practice Address - Zip Code:54021-7038
Practice Address - Country:US
Practice Address - Phone:715-262-4441
Practice Address - Fax:715-262-4443
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-20
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3114-23363A00000X
MN10924363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant