Provider Demographics
NPI:1750628046
Name:OLIVAREZ, JENNIFER LYNNE (PA)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNNE
Last Name:OLIVAREZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:LYNNE
Other - Last Name:MENDIOLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:809 82ND PARKWAY
Mailing Address - Street 2:GME OFFICE
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572
Mailing Address - Country:US
Mailing Address - Phone:843-692-1752
Mailing Address - Fax:843-692-1904
Practice Address - Street 1:809 82ND PKWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4607
Practice Address - Country:US
Practice Address - Phone:184-369-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-07
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08394363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant