Healthcare Provider Details

I. General information

NPI: 1508418294
Provider Name (Legal Business Name): JENNIFER L MAYBERRY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2019
Last Update Date: 11/30/2023
Certification Date: 11/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 S STATE ST MAIL CODE 1127
DOVER DE
19901-3530
US

IV. Provider business mailing address

640 S STATE ST MAIL CODE 3055
DOVER DE
19901-3530
US

V. Phone/Fax

Practice location:
  • Phone: 302-744-7062
  • Fax:
Mailing address:
  • Phone: 302-480-1688
  • Fax: 302-480-9807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC5-0011416
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: