Provider Demographics
NPI:1952345654
Name:STEVENS, JENNIFER M (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:STEVENS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1205 PROVIDENT DR
Mailing Address - Street 2:STE A
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580-3265
Mailing Address - Country:US
Mailing Address - Phone:574-269-8383
Mailing Address - Fax:574-269-8384
Practice Address - Street 1:1205 PROVIDENT DR
Practice Address - Street 2:STE A
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3265
Practice Address - Country:US
Practice Address - Phone:574-269-8383
Practice Address - Fax:574-269-8384
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN10000558A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000529131OtherANTHEM
453220XXMedicare PIN