1790976330 NPI number — JENNIFER STARR DAVIS PA-C

Table of content: JENNIFER STARR DAVIS PA-C (NPI 1790976330)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790976330 NPI number — JENNIFER STARR DAVIS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
JENNIFER
Provider Middle Name:
STARR
Provider Name Prefix Text:
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:
BOYER
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
STARR
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1790976330
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
02/22/2019
NPI Reactivation Date:
03/06/2019

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 361095
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MELBOURNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32936-1095
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-254-7717
Provider Business Mailing Address Fax Number:
321-428-4526

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1305 VALENTINE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32901-3127
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-254-7717
Provider Business Practice Location Address Fax Number:
321-428-4526
Provider Enumeration Date:
08/08/2007

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: 363A00000X , with the licence number:  4357 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 9104207 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: Y04VT . This is a "FLORIDA BLUE (BCBS OF FL)" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P01165507 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 119580700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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