Provider Demographics
NPI:1871051557
Name:GEORGE, JENNIFER SUSAN (PA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUSAN
Last Name:GEORGE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1218 MOUNTAIN LAKE DR
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-1510
Mailing Address - Country:US
Mailing Address - Phone:832-327-4632
Mailing Address - Fax:
Practice Address - Street 1:2510 30TH AVE
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11102-2448
Practice Address - Country:US
Practice Address - Phone:718-932-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023378-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical