Basic Information
Provider Information | |||||||||
NPI: | 1164855268 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SIKORSKI | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LANCE | ||||||||
OtherFirstName: | JENNIFER | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 413 SOUTH CRANFORD RD | ||||||||
Address2: |   | ||||||||
City: | CHERRY HILL | ||||||||
State: | NJ | ||||||||
PostalCode: | 08003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8569126397 | ||||||||
FaxNumber: | 2159572875 | ||||||||
Practice Location | |||||||||
Address1: | 1600 HADDON AVE | ||||||||
Address2: |   | ||||||||
City: | CAMDEN | ||||||||
State: | NJ | ||||||||
PostalCode: | 08103 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8567573803 | ||||||||
FaxNumber: | 8563657773 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/13/2013 | ||||||||
LastUpdateDate: | 12/06/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/06/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 25MP00311500 | NJ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 25MP00311500 | NJ | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.