Provider Demographics
NPI:1851799027
Name:FAYETTE, JENNIFER ANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANNE
Last Name:FAYETTE
Suffix:
Gender:F
Credentials: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:PO BOX 112069
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99511-2069
Mailing Address - Country:US
Mailing Address - Phone:907-646-7847
Mailing Address - Fax:907-646-7847
Practice Address - Street 1:2741 DEBARR RD STE C408
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-2980
Practice Address - Country:US
Practice Address - Phone:907-646-7846
Practice Address - Fax:907-646-7847
Is Sole Proprietor?:No
Enumeration Date:2014-12-19
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKPADA1232363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1627131Medicaid
AKK167162Medicare PIN