Provider Demographics
NPI:1922029560
Name:FERGUSON, JENNIFFER SUE (PAC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFFER
Middle Name:SUE
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MS
Other - First Name:JENNIFFER
Other - Middle Name:SUE
Other - Last Name:ELWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:601 E DIXIE AVE
Mailing Address - Street 2:PLAZA 901
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-5998
Mailing Address - Country:US
Mailing Address - Phone:352-728-2404
Mailing Address - Fax:352-787-7401
Practice Address - Street 1:601 E DIXIE AVE
Practice Address - Street 2:PLAZA 901
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5998
Practice Address - Country:US
Practice Address - Phone:352-728-2404
Practice Address - Fax:352-787-7401
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103323363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292263100Medicaid
FLU6373ZMedicare PIN
FLU6373YMedicare PIN
Q56472Medicare UPIN