Provider Demographics
NPI:1144991480
Name:GAMBLE, JENNIFER (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GAMBLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3411 SILVERSIDE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19810-4811
Mailing Address - Country:US
Mailing Address - Phone:302-543-5454
Mailing Address - Fax:302-327-4200
Practice Address - Street 1:3411 SILVERSIDE RD STE 100
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19810-4811
Practice Address - Country:US
Practice Address - Phone:302-543-5454
Practice Address - Fax:302-327-4200
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-27
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0011583363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEC5-0011583OtherSTATE PROFESSIONAL LICENSE
DEDA-0024779OtherSTATE CONTROLLED SUBSTANCE LICENSE