Provider Demographics
NPI:1568567899
Name:GODLEWSKI, JENNIFER MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:GODLEWSKI
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:PO BOX 510
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13214-0510
Mailing Address - Country:US
Mailing Address - Phone:315-552-6700
Mailing Address - Fax:
Practice Address - Street 1:5496 E TAFT RD
Practice Address - Street 2:
Practice Address - City:NORTH SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-3773
Practice Address - Country:US
Practice Address - Phone:315-552-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015166-1363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03439278Medicaid