Provider Demographics
NPI:1053072173
Name:OLIVER, JENNY ANNE (PA-C)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:ANNE
Last Name:OLIVER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNY
Other - Middle Name:ANNE
Other - Last Name:VAN WAGONER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 BREWSTER BLVD
Mailing Address - Street 2:
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28547-2575
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 BREWSTER BLVD
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547-2575
Practice Address - Country:US
Practice Address - Phone:910-450-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-02
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-14138363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant