Provider Demographics
NPI:1437298015
Name:FARRELL, JENNIFER MARIE (MPAS, PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARIE
Last Name:FARRELL
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:MARIE
Other - Last Name:FUNK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPAS, PA-C
Mailing Address - Street 1:500 VONDERBURG DR
Mailing Address - Street 2:SUIT 102
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5964
Mailing Address - Country:US
Mailing Address - Phone:813-681-5658
Mailing Address - Fax:813-681-5250
Practice Address - Street 1:500 VONDERBURG DR
Practice Address - Street 2:SUIT 102
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5964
Practice Address - Country:US
Practice Address - Phone:813-681-5658
Practice Address - Fax:813-681-5250
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103278363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant