Provider Demographics
NPI:1942644521
Name:TRUCKENBROD, JENNA SOMMER (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:SOMMER
Last Name:TRUCKENBROD
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 1:964 FAWN PKWY
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154-3531
Mailing Address - Country:US
Mailing Address - Phone:605-370-7823
Mailing Address - Fax:
Practice Address - Street 1:1205 S GRANGE AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-0407
Practice Address - Country:US
Practice Address - Phone:605-328-9290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-25
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1737363AM0700X, 363A00000X
SD1040363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical