Provider Demographics
NPI:1710411426
Name:HAM, JENNIFER ANNE (CST, CSFA)
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:ANNE
Last Name:HAM
Suffix:
Gender:F
Credentials:CST, CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 SEABREEZE DR
Mailing Address - Street 2:
Mailing Address - City:GUN BARREL CITY
Mailing Address - State:TX
Mailing Address - Zip Code:75156-5644
Mailing Address - Country:US
Mailing Address - Phone:903-603-8386
Mailing Address - Fax:
Practice Address - Street 1:201 SEABREEZE DR
Practice Address - Street 2:
Practice Address - City:GUN BARREL CITY
Practice Address - State:TX
Practice Address - Zip Code:75156-5644
Practice Address - Country:US
Practice Address - Phone:903-603-8386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-19
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
170804363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical