Provider Demographics
NPI:1619366192
Name:JENNINGS, LAURA LYNNE (PA-C)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LYNNE
Last Name:JENNINGS
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 1:339 E STREET RD
Mailing Address - Street 2:
Mailing Address - City:TREVOSE
Mailing Address - State:PA
Mailing Address - Zip Code:19053-7711
Mailing Address - Country:US
Mailing Address - Phone:215-464-4111
Mailing Address - Fax:267-574-8111
Practice Address - Street 1:339 E STREET RD
Practice Address - Street 2:
Practice Address - City:TREVOSE
Practice Address - State:PA
Practice Address - Zip Code:19053-7711
Practice Address - Country:US
Practice Address - Phone:215-464-4111
Practice Address - Fax:267-574-8111
Is Sole Proprietor?:No
Enumeration Date:2015-01-21
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA057440363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant