Provider Demographics
NPI:1922770346
Name:MICHALAK, JENNIFER ANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANNE
Last Name:MICHALAK
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 1:720 OAKLAND HILLS CIR APT 204
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5830
Mailing Address - Country:US
Mailing Address - Phone:412-715-5381
Mailing Address - Fax:
Practice Address - Street 1:1530 CORNERSTONE BLVD STE 120
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-7129
Practice Address - Country:US
Practice Address - Phone:386-310-2160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-04
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9115118363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113008300Medicaid