Provider Demographics
NPI:1205893666
Name:FORTHMAN, JENNIFER D (PA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:D
Last Name:FORTHMAN
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 1:105 W E ST
Mailing Address - Street 2:PO BOX 1900
Mailing Address - City:TEHACHAPI
Mailing Address - State:CA
Mailing Address - Zip Code:93561-1607
Mailing Address - Country:US
Mailing Address - Phone:661-823-7070
Mailing Address - Fax:
Practice Address - Street 1:105 W E ST
Practice Address - Street 2:
Practice Address - City:TEHACHAPI
Practice Address - State:CA
Practice Address - Zip Code:93561-1607
Practice Address - Country:US
Practice Address - Phone:661-823-7070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1523363A00000X
CA22143363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200075940AMedicaid
OK200075940AMedicaid
OK24H619032Medicare PIN
OKQ65128Medicare UPIN
OK24H620538Medicare PIN
OK247606502Medicare PIN