Provider Demographics
NPI:1518215862
Name:THIBODEAU, JENNA DEES (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNA
Middle Name:DEES
Last Name:THIBODEAU
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4371 VERONICA S SHOEMAKER BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-2216
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:239-278-3350
Practice Address - Street 1:8931 COLONIAL CENTER DR
Practice Address - Street 2:#300
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-7816
Practice Address - Country:US
Practice Address - Phone:239-938-0800
Practice Address - Fax:239-938-0890
Is Sole Proprietor?:No
Enumeration Date:2012-08-16
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107881363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ731662Medicaid