Provider Demographics
NPI:1528216389
Name:DESTEFANO, JENNIFER LEIGH (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LEIGH
Last Name:DESTEFANO
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 1:230 WEST PARKWAY
Mailing Address - Street 2:UNIT #10
Mailing Address - City:POMPTON PLAINS
Mailing Address - State:NJ
Mailing Address - Zip Code:07444
Mailing Address - Country:US
Mailing Address - Phone:973-835-0800
Mailing Address - Fax:973-616-2766
Practice Address - Street 1:230 WEST PARKWAY
Practice Address - Street 2:UNIT #10
Practice Address - City:POMPTON PLAINS
Practice Address - State:NJ
Practice Address - Zip Code:07444
Practice Address - Country:US
Practice Address - Phone:973-835-0800
Practice Address - Fax:973-616-2766
Is Sole Proprietor?:No
Enumeration Date:2008-09-05
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00058600363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
O38491Medicare UPIN