Provider Demographics
NPI:1952368037
Name:PASSANTINO, JENNIFER JO (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JO
Last Name:PASSANTINO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:JO
Other - Last Name:STRONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:
Practice Address - Street 1:345 FRESHFIELDS DRIVE
Practice Address - Street 2:SUITE J101
Practice Address - City:JOHNS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29455-6323
Practice Address - Country:US
Practice Address - Phone:843-768-4800
Practice Address - Fax:843-606-8039
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC659363A00000X
PAMA055001363A00000X
OH50002137363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0232PAMedicaid
OHPAPA23881Medicare ID - Type Unspecified
K53196Medicare PIN