Provider Demographics
NPI:1497709406
Name:THOMPSON, JENNIFER ELLEN (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELLEN
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ELLEN
Other - Last Name:SECORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4525 SW 13TH ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-3901
Mailing Address - Country:US
Mailing Address - Phone:352-377-8619
Mailing Address - Fax:352-371-9674
Practice Address - Street 1:4525 SW 13TH ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-3901
Practice Address - Country:US
Practice Address - Phone:352-377-8619
Practice Address - Fax:352-371-9674
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102686363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009862200Medicaid
FLQ13804Medicare UPIN
FLU2086YMedicare PIN