Provider Demographics
NPI:1649365610
Name:EVANS, JENNY A (PA)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:A
Last Name:EVANS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JENNY
Other - Middle Name:A
Other - Last Name:MOULTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:500 MERRIMACK ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01843-1756
Mailing Address - Country:US
Mailing Address - Phone:978-557-8900
Mailing Address - Fax:978-557-8633
Practice Address - Street 1:360 MERRIMACK ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01843-1740
Practice Address - Country:US
Practice Address - Phone:978-557-8800
Practice Address - Fax:978-557-8633
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1857363A00000X
NH0603363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30334648Medicaid
ME432389499Medicaid
NHP00791691OtherRAILROAD MEDICARE
NHQ35212Medicare UPIN
ME432389499Medicaid