Provider Demographics
NPI:1407839616
Name:WREN, JENNIFER RENEE (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RENEE
Last Name:WREN
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 1:1820 BARRS ST
Mailing Address - Street 2:SUITE 701
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4742
Mailing Address - Country:US
Mailing Address - Phone:904-421-5586
Mailing Address - Fax:904-389-6748
Practice Address - Street 1:1820 BARRS ST
Practice Address - Street 2:SUITE 701
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4742
Practice Address - Country:US
Practice Address - Phone:904-421-5586
Practice Address - Fax:904-389-6748
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103522363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU6637ZMedicare ID - Type UnspecifiedPROVIDER NUMBER
FLQ60415Medicare UPIN