Provider Demographics
NPI:1831359538
Name:FERGUSON, JENNIFER LYNN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:FERGUSON
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 1:1455 FRAZEE RD STE 220
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4303
Mailing Address - Country:US
Mailing Address - Phone:800-270-5016
Mailing Address - Fax:
Practice Address - Street 1:1455 FRAZEE RD STE 220
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4303
Practice Address - Country:US
Practice Address - Phone:800-270-5016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-16
Last Update Date:2020-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA55977363A00000X
VA0110003886363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant