Provider Demographics
NPI:1457389488
Name:DELLINGER, JENNIE MARIE (PA)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:MARIE
Last Name:DELLINGER
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:PO BOX 60099
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0099
Mailing Address - Country:US
Mailing Address - Phone:704-512-3930
Mailing Address - Fax:704-865-2478
Practice Address - Street 1:1896 REMOUNT RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-7414
Practice Address - Country:US
Practice Address - Phone:704-512-3930
Practice Address - Fax:704-865-2478
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101002363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2844PAMedicaid
NC8101844Medicaid
NC1457389488Medicaid
NC1457389488Medicaid
SC2844PAMedicaid
NC2747451Medicare PIN