Provider Demographics
NPI:1699838920
Name:DORMANN, JENNA M (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:M
Last Name:DORMANN
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 1:2822 JACKSON BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-3497
Mailing Address - Country:US
Mailing Address - Phone:605-341-1208
Mailing Address - Fax:605-341-3552
Practice Address - Street 1:2822 JACKSON BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-3497
Practice Address - Country:US
Practice Address - Phone:605-341-1208
Practice Address - Fax:605-341-3552
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0614363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0001972OtherWELLMARK
SD6828382Medicaid
SD6828382Medicaid
SD100902Medicare ID - Type Unspecified