1346790417 NPI number — MISS JENNA MARIE AINSWORTH PA-C

Table of content: MISS JENNA MARIE AINSWORTH PA-C (NPI 1346790417)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346790417 NPI number — MISS JENNA MARIE AINSWORTH PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AINSWORTH
Provider First Name:
JENNA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HABERMAN
Provider Other First Name:
JENNA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1346790417
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1006 TREETOPS BLVD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
FLOWOOD
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39232-7645
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-939-0005
Provider Business Mailing Address Fax Number:
601-936-4949

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1006 TREETOPS BLVD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
FLOWOOD
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39232-7645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-939-0005
Provider Business Practice Location Address Fax Number:
601-936-4949
Provider Enumeration Date:
10/12/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA00303 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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