Provider Demographics
NPI:1841233384
Name:MCCALLA, JENNIFER (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MCCALLA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3885 SILVER CHARM LN
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-9215
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:620 BYRON RD
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-1002
Practice Address - Country:US
Practice Address - Phone:517-545-6318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1070260363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant