Provider Demographics
NPI:1720243975
Name:DODSON, JENNY MARIA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNY
Middle Name:MARIA
Last Name:DODSON
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 1:14050 NW 14TH ST
Mailing Address - Street 2:SUITE 190
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2865
Mailing Address - Country:US
Mailing Address - Phone:954-377-3134
Mailing Address - Fax:865-560-7377
Practice Address - Street 1:922 E CALL ST
Practice Address - Street 2:
Practice Address - City:STARKE
Practice Address - State:FL
Practice Address - Zip Code:32091-3616
Practice Address - Country:US
Practice Address - Phone:904-368-2300
Practice Address - Fax:386-292-8295
Is Sole Proprietor?:No
Enumeration Date:2008-07-26
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPAT9104645363A00000X
FLPA9104645363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000339800Medicaid
AX667YMedicare PIN