Provider Demographics
NPI:1477614089
Name:EDWARDS, JENNIFER MARIE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:MARIE
Last Name:EDWARDS
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:P.O. BOX 91694
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90009-1694
Mailing Address - Country:US
Mailing Address - Phone:323-908-4200
Mailing Address - Fax:323-908-4262
Practice Address - Street 1:4425 SOUTH CENTRAL AVE.
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90009-1694
Practice Address - Country:US
Practice Address - Phone:323-908-4200
Practice Address - Fax:323-908-4262
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14956363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical