Provider Demographics
NPI:1548509052
Name:ROLLER, JENNA ELIZABETH (PA-C)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:ELIZABETH
Last Name:ROLLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:E
Other - Last Name:BERNINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7419 KIMBARK CT
Mailing Address - Street 2:APT. E
Mailing Address - City:ROSEDALE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-3736
Mailing Address - Country:US
Mailing Address - Phone:610-417-0273
Mailing Address - Fax:
Practice Address - Street 1:15 MOSS CREEK VLG
Practice Address - Street 2:
Practice Address - City:HILTON HEAD
Practice Address - State:SC
Practice Address - Zip Code:29926-1105
Practice Address - Country:US
Practice Address - Phone:843-681-5077
Practice Address - Fax:843-681-5012
Is Sole Proprietor?:No
Enumeration Date:2013-02-04
Last Update Date:2018-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2950207X00000X
MDC0004965363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
11011359OtherNCCPA
C0004965OtherMARYLAND BOARD OF PHYSICIANS
SC2950OtherSC PA LICENSE