Provider Demographics
NPI:1295079226
Name:STIFTER, JENNIFER LAUREN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LAUREN
Last Name:STIFTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:LAUREN
Other - Last Name:RALSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:800 PRUDENTIAL DRIVE
Mailing Address - Street 2:TOWER B, 11TH FLOOR
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-9046
Mailing Address - Country:US
Mailing Address - Phone:904-388-6518
Mailing Address - Fax:904-384-1005
Practice Address - Street 1:800 PRUDENTIAL DRIVE
Practice Address - Street 2:TOWER B, 11TH FLOOR
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-9046
Practice Address - Country:US
Practice Address - Phone:904-388-6518
Practice Address - Fax:904-384-1005
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106779363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant