Provider Demographics
NPI:1942709217
Name:MORTON, JENNA MAYFIELD (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:MAYFIELD
Last Name:MORTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:NICHOLE
Other - Last Name:MAYFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3590 PIAZZA DR APT 110
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-8111
Mailing Address - Country:US
Mailing Address - Phone:931-808-1414
Mailing Address - Fax:
Practice Address - Street 1:200 S PARK RD STE 200
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-8541
Practice Address - Country:US
Practice Address - Phone:866-986-2263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-01
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3516363A00000X
FLPA9115138363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty