Provider Demographics
NPI:1578825105
Name:PENNE, JAYNE R (PA-C)
Entity type:Individual
Prefix:
First Name:JAYNE
Middle Name:R
Last Name:PENNE
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:PO BOX 936
Mailing Address - Street 2:EVMS MEDICAL GROUP
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23501-0936
Mailing Address - Country:US
Mailing Address - Phone:757-446-8920
Mailing Address - Fax:757-446-5242
Practice Address - Street 1:825 FAIRFAX AVE
Practice Address - Street 2:SUITE 445
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1914
Practice Address - Country:US
Practice Address - Phone:757-446-8920
Practice Address - Fax:757-446-5242
Is Sole Proprietor?:No
Enumeration Date:2012-06-11
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003827363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10120878POtherOPTIMA HEALTH
VA1578825105Medicaid
VAPAROtherUSA MANAGED CARE
VAPAROtherCORVEL
NC1578825105Medicaid
VAPAROtherMULTIPLAN
VAPAROtherMULTIPLAN
VA1578825105Medicaid