Provider Demographics
NPI:1477597169
Name:HERDMAN, JENNIFER L (PA)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:L
Last Name:HERDMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:OLIVIERI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1005 LEXINGTON DOWNS DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-7203
Mailing Address - Country:US
Mailing Address - Phone:252-414-8271
Mailing Address - Fax:
Practice Address - Street 1:101 HEART DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-8982
Practice Address - Country:US
Practice Address - Phone:252-744-4611
Practice Address - Fax:252-816-0762
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001773363A00000X
NC0010-01611363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAS96783Medicaid