Provider Demographics
NPI:1750483244
Name:MODESTO, JENNIFER CHRISTINE (BS, PA-C)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:CHRISTINE
Last Name:MODESTO
Suffix:
Gender:F
Credentials:BS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7960 N WICKHAM RD STE 103
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-8096
Mailing Address - Country:US
Mailing Address - Phone:321-428-4737
Mailing Address - Fax:
Practice Address - Street 1:7960 N WICKHAM RD STE 103
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-8096
Practice Address - Country:US
Practice Address - Phone:321-428-4737
Practice Address - Fax:321-241-6457
Is Sole Proprietor?:No
Enumeration Date:2006-09-04
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004881363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00349237OtherMEDICARE RAILROAD
7463850OtherAETNA
MIP00349237OtherMEDICARE RAILROAD