Provider Demographics
NPI:1255890869
Name:CASSATT, JENNIFER RAYE (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RAYE
Last Name:CASSATT
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 1:1236 E RUSHOLME ST STE 150
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-2433
Mailing Address - Country:US
Mailing Address - Phone:563-421-3990
Mailing Address - Fax:563-421-3999
Practice Address - Street 1:1236 E RUSHOLME ST STE 150
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-2433
Practice Address - Country:US
Practice Address - Phone:563-421-3990
Practice Address - Fax:563-421-3999
Is Sole Proprietor?:No
Enumeration Date:2019-03-14
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA095841363A00000X
IL085.006961363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1255890869Medicaid