Basic Information
| Provider Information | |||||||||
| NPI: | 1255890869 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CASSATT | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | RAYE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1236 E RUSHOLME ST STE 150 | ||||||||
| Address2: | |||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528032433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5634213990 | ||||||||
| FaxNumber: | 5634213999 | ||||||||
| Practice Location | |||||||||
| Address1: | 1236 E RUSHOLME ST STE 150 | ||||||||
| Address2: | |||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528032433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5634213990 | ||||||||
| FaxNumber: | 5634213999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2019 | ||||||||
| LastUpdateDate: | 08/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 095841 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 085.006961 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1255890869 | 05 | IL | MEDICAID |