Provider Demographics
NPI:1477502391
Name:HANLEY, JENNIFER A (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:A
Last Name:HANLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:ABBOUD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 361095
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32936-1095
Mailing Address - Country:US
Mailing Address - Phone:321-254-7717
Mailing Address - Fax:321-255-2361
Practice Address - Street 1:2200 W EAU GALLIE BLVD STE 202B
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-3166
Practice Address - Country:US
Practice Address - Phone:321-254-7717
Practice Address - Fax:321-255-2361
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100969363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9287537OtherAETNA PIN
FLY04UHOtherFLORIDA BLUE BCBS#
FL290574400Medicaid
FL290574400Medicaid
FLS83078Medicare UPIN