Provider Demographics
NPI:1699819284
Name:WOLGAST, JENNIFER LYNN (NP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:WOLGAST
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 MOTOR RD
Mailing Address - Street 2:
Mailing Address - City:PINE BEACH
Mailing Address - State:NJ
Mailing Address - Zip Code:08741-1036
Mailing Address - Country:US
Mailing Address - Phone:732-330-0233
Mailing Address - Fax:732-473-0479
Practice Address - Street 1:411 MOTOR RD
Practice Address - Street 2:
Practice Address - City:PINE BEACH
Practice Address - State:NJ
Practice Address - Zip Code:08741-1036
Practice Address - Country:US
Practice Address - Phone:732-330-0233
Practice Address - Fax:732-473-0479
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NN09102100363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ9082905Medicaid