MEDICARE: JENNA M DORMANN 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	363AM0700X	Medical Physician Assistant	0614	SD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0001972	OTHER	SD	WELLMARK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699838920
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNA M DORMANN PA-C

Provider Business Mailing Address
First Line	:	2822 JACKSON BLVD
Second Line	:	SUITE 101
City	:	RAPID CITY
State	:	SD
Zip	:	57702-3497
Country	:	US
Telephone Number	:	605-341-1208
Fax Number	:	605-341-3552

Provider Business Practice Location Address
First Line	:	2822 JACKSON BLVD
Second Line	:	SUITE 101
City	:	RAPID CITY
State	:	SD
Zip	:	57702-3497
Country	:	US
Telephone Number	:	605-341-1208
Fax Number	:	605-341-3552

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

Provider Enumeration Date	:	12/18/2006
Last Update Date	:	01/14/2016

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Directions to “ JENNA M DORMANN PA-C” Practice Location

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