Provider Demographics
NPI:1619232519
Name:CROCKETT, JENNA (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:C
Other - Last Name:NASH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:730 THIMBLE SHOALS BLVD STE 130
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4562
Mailing Address - Country:US
Mailing Address - Phone:757-873-1554
Mailing Address - Fax:757-873-3239
Practice Address - Street 1:730 THIMBLE SHOALS BLVD STE 130
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4562
Practice Address - Country:US
Practice Address - Phone:757-873-1554
Practice Address - Fax:757-873-3239
Is Sole Proprietor?:No
Enumeration Date:2012-07-07
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10124928POtherOPTIMA HEALTH
VA513047OtherBCBS SUPPLEMENT
VA1619232519Medicaid
VA1619232519OtherHUMANA
VA1619232519OtherTRICARE STANDARD AND PRIME