Provider Demographics
NPI:1013980150
Name:ADAMS, JENNIFER (PA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:ADAMS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4948 BENCHMARK CENTRE DR
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-2027
Mailing Address - Country:US
Mailing Address - Phone:618-628-2588
Mailing Address - Fax:618-628-1363
Practice Address - Street 1:4948 BENCHMARK CENTRE DR
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-2027
Practice Address - Country:US
Practice Address - Phone:618-628-2588
Practice Address - Fax:618-628-1363
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011024401363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q46470Medicare UPIN
K18512Medicare ID - Type Unspecified