Provider Demographics
NPI:1619087095
Name:ST. LOUIS, JENNIFER K (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:K
Last Name:ST. LOUIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 15TH ST STE BI1056
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-0004
Mailing Address - Country:US
Mailing Address - Phone:706-721-3813
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH STREET
Practice Address - Street 2:DEPARTMENT OF SURGERY
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-3091
Practice Address - Country:US
Practice Address - Phone:706-721-8623
Practice Address - Fax:706-721-1459
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003197363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1619087095OtherNPI
GA063545175AMedicaid
Q66326Medicare UPIN
GA97WCHLCMedicare ID - Type UnspecifiedGA MEDICARE #