Provider Demographics
NPI:1790976330
Name:DAVIS, JENNIFER STARR (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:STARR
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:STARR
Other - Last Name:BOYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 361095
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32936-1095
Mailing Address - Country:US
Mailing Address - Phone:321-254-7717
Mailing Address - Fax:321-428-4526
Practice Address - Street 1:1305 VALENTINE ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3127
Practice Address - Country:US
Practice Address - Phone:321-254-7717
Practice Address - Fax:321-428-4526
Is Sole Proprietor?:No
Enumeration Date:2007-08-08
Last Update Date:2023-08-28
Deactivation Date:2019-02-22
Deactivation Code:
Reactivation Date:2019-03-06
Provider Licenses
StateLicense IDTaxonomies
AZ4357363A00000X
FL9104207363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY04VTOtherFLORIDA BLUE (BCBS OF FL)
FLP01165507OtherRR MEDICARE
FLY04VTOtherFLORIDA BLUE (BCBS OF FL)