Provider Demographics
NPI:1447212162
Name:ROTHENBERGER, JENNIFER S (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:S
Last Name:ROTHENBERGER
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 1:12040 NE 128TH ST
Mailing Address - Street 2:# MS-50
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-3013
Mailing Address - Country:US
Mailing Address - Phone:425-899-1894
Mailing Address - Fax:425-899-1898
Practice Address - Street 1:8333 NAAB RD STE 250
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260
Practice Address - Country:US
Practice Address - Phone:317-396-1300
Practice Address - Fax:317-396-1346
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101661363AS0400X
WAPA60995158363AS0400X
IN10002582A363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291359300Medicaid
FL2913593-00Medicaid
FL2913593-00Medicaid
FLE6582YMedicare ID - Type Unspecified