Provider Demographics
NPI:1982779633
Name:HAZZARD, JENNIFER JOHNSON (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:JOHNSON
Last Name:HAZZARD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:RENEE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 607
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19947-0607
Mailing Address - Country:US
Mailing Address - Phone:302-424-4141
Mailing Address - Fax:302-422-6506
Practice Address - Street 1:1606 SAVANNAH RD
Practice Address - Street 2:
Practice Address - City:LEWES
Practice Address - State:DE
Practice Address - Zip Code:19958-1656
Practice Address - Country:US
Practice Address - Phone:302-424-4141
Practice Address - Fax:302-422-6506
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0000566363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1982779633Medicaid
1982779633OtherBLUE CROSS BLUE SHIELD OF DELAWARE
51-0370286OtherHEALTH NET - TRICARE/CHAMPUS
51-0370286OtherUNION LABOR LIFE INSURANCE COMPANY
P00472436OtherRAILROAD MEDICARE
51-0370286OtherGREAT-WEST HEALTH CARE
51-0370286OtherDEVON HEALTH SERVICES
DE51-0370286OtherEASTERN SUSSEX PHYSICIANS CARE
6189710002Medicare NSC
1982779633OtherBLUE CROSS BLUE SHIELD OF DELAWARE
021084023Medicare PIN