Provider Demographics
NPI:1508005661
Name:KMIECINSKI, JENNIFER LEA (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEA
Last Name:KMIECINSKI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:CROFT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 758952
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-8952
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:5125 JONESTOWN RD
Practice Address - Street 2:SUITE 105
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17112-2990
Practice Address - Country:US
Practice Address - Phone:717-943-1566
Practice Address - Fax:717-943-1567
Is Sole Proprietor?:No
Enumeration Date:2009-02-13
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053799363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA508469YUNMMedicare PIN
PA149047Medicare PIN
PA508469YEBKMedicare PIN