Provider Demographics
NPI:1992856413
Name:ERICKSON, JENNIFER ANNE (NP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ANNE
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:ANNE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-926-9022
Mailing Address - Fax:215-226-8286
Practice Address - Street 1:7602 CENTRAL AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-2443
Practice Address - Country:US
Practice Address - Phone:215-969-2900
Practice Address - Fax:215-969-1856
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP007259363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASM1374026OtherPENNSYLVANIA BLUESHIELD
PA500025007OtherRAILROAD MEDICARE #
PA07791408OtherPROVIDER TYPE 57 ID NUMBE
PA07791408OtherPROVIDER TYPE 57 ID NUMBE