MEDICARE: MS. JENNIFER CHRISTINE MODESTO B.S., PA-C

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	5601004881	MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00349237	OTHER	MI	MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	7463850	OTHER		AETNA

General Provider Information

NPI Number	:	1750483244
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JENNIFER CHRISTINE MODESTO B.S., PA-C

Provider Business Mailing Address
First Line	:	7960 N WICKHAM RD STE 103
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32940-8096
Country	:	US
Telephone Number	:	321-428-4737
Fax Number	:

Provider Business Practice Location Address
First Line	:	7960 N WICKHAM RD STE 103
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32940-8096
Country	:	US
Telephone Number	:	321-428-4737
Fax Number	:	321-241-6457

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

Provider Enumeration Date	:	09/04/2006
Last Update Date	:	12/17/2020

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