Provider Demographics
NPI:1578506614
Name:GINGRICH, JENNIFER LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:GINGRICH
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 1:877 OAK PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-3292
Mailing Address - Country:US
Mailing Address - Phone:805-474-8450
Mailing Address - Fax:805-474-8454
Practice Address - Street 1:877 OAK PARK BLVD
Practice Address - Street 2:
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-3292
Practice Address - Country:US
Practice Address - Phone:805-474-8450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17013363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP39685Medicare UPIN
CAWPA17013AMedicare PIN