1245424829 NPI number — MRS. JENNA MARIE LITTLE PA-C

Table of content: MRS. JENNA MARIE LITTLE PA-C (NPI 1245424829)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245424829 NPI number — MRS. JENNA MARIE LITTLE PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LITTLE
Provider First Name:
JENNA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
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:
JONES
Provider Other First Name:
JENNA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1245424829
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1300 HORIZON DR
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
CHALFONT
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18914-3970
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-489-9170
Provider Business Mailing Address Fax Number:
215-489-9174

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 CHASE PKWY
Provider Second Line Business Practice Location Address:
SUITE 2B
Provider Business Practice Location Address City Name:
WATERBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06708-3346
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-755-6677
Provider Business Practice Location Address Fax Number:
203-755-7166
Provider Enumeration Date:
08/28/2007

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: 363AS0400X , with the licence number:  50.002600 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 50.002600 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X , with the licence number: 003290 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 003290 . This is a "CONNECTICUT LICENSE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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