Provider Demographics
NPI:1871500553
Name:HAUGEN, JENNIFER L (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:HAUGEN
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11304 HAWTHORNE DR
Practice Address - Street 2:STE 100
Practice Address - City:MINT HILL
Practice Address - State:NC
Practice Address - Zip Code:28227-9425
Practice Address - Country:US
Practice Address - Phone:704-545-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102061363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC56162OtherMEDCOST
NC1871500553Medicaid
NC8101276Medicaid
SC0387PAMedicaid
NCNC4675EMedicare PIN
NC2746388FMedicare PIN
SC0387PAMedicaid
NCNC4675JMedicare PIN
NCNC4675GMedicare PIN
NCNC4657BMedicare PIN
NC1871500553Medicaid
NC56162OtherMEDCOST
NCNC4675CMedicare PIN