Provider Demographics
NPI:1508142803
Name:CABALLERO, JENNIFER EDEN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:EDEN
Last Name:CABALLERO
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 1:1921 WALDEMERE ST STE 705
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-2913
Mailing Address - Country:US
Mailing Address - Phone:941-366-5864
Mailing Address - Fax:941-316-9819
Practice Address - Street 1:1921 WALDEMERE ST STE 705
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2913
Practice Address - Country:US
Practice Address - Phone:941-366-5864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-31
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9106259363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0016967300Medicaid