Provider Demographics
NPI:1932486099
Name:HENKIN, JESSICA R (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:R
Last Name:HENKIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:R
Other - Last Name:MOSKOWITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1 MEDICAL CENTER DRIVE
Mailing Address - Street 2:DARTMOUTH HITCHCOCK - GENERAL SURGERY
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03756
Mailing Address - Country:US
Mailing Address - Phone:603-650-5211
Mailing Address - Fax:
Practice Address - Street 1:ONE MEDICAL CENTER DRIVE
Practice Address - Street 2:DARTMOUTH HITCHCOCK - GENERAL SURGERY
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756
Practice Address - Country:US
Practice Address - Phone:603-650-5211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-03
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1253363A00000X, 363AM0700X
MN11310363A00000X
MAPA4261363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MN970007007Medicare PIN