Provider Demographics
NPI:1356409742
Name:DEFORGE, JENNIFER L (ARNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:DEFORGE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1395 N COURTENAY PKWY STE 107
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-4474
Mailing Address - Country:US
Mailing Address - Phone:321-453-1955
Mailing Address - Fax:321-454-2406
Practice Address - Street 1:1395 N COURTENAY PKWY STE 107
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953
Practice Address - Country:US
Practice Address - Phone:321-453-1955
Practice Address - Fax:321-639-5177
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9200700363LA2200X
FLARNP9200700363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLARNP9200700OtherLICENSE
FL308047100Medicaid
FLU8941ZMedicare PIN