MEDICARE: MS. JENNIFER R ADDINGTON PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	3114-23	WI
2	363A00000X	Physician Assistant	10924	MN

General Provider Information

NPI Number	:	1417245739
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JENNIFER R ADDINGTON PAC

Provider Business Mailing Address
First Line	:	1387 FOREST ST
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55106-1811
Country	:	US
Telephone Number	:	651-235-5278
Fax Number	:

Provider Business Practice Location Address
First Line	:	1400 N ACRES RD
Second Line	:
City	:	PRESCOTT
State	:	WI
Zip	:	54021-7038
Country	:	US
Telephone Number	:	715-262-4441
Fax Number	:	715-262-4443

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2011
Last Update Date	:	03/11/2021

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