Provider Demographics
NPI:1447364823
Name:HALL, JENNIFER A (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:HALL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 S HACKETT RD
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50701-3500
Mailing Address - Country:US
Mailing Address - Phone:319-274-1000
Mailing Address - Fax:319-292-6526
Practice Address - Street 1:1015 S HACKETT RD
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-3500
Practice Address - Country:US
Practice Address - Phone:319-274-1000
Practice Address - Fax:319-292-6526
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001614363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI16022Medicare ID - Type UnspecifiedMEDICARE
IAQ51715Medicare UPIN