Provider Demographics
NPI:1861594087
Name:RORVIG, JENA L (PA)
Entity type:Individual
Prefix:
First Name:JENA
Middle Name:L
Last Name:RORVIG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JENA
Other - Middle Name:L
Other - Last Name:SHACKELFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 S KEENE ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-7199
Mailing Address - Country:US
Mailing Address - Phone:573-876-8417
Mailing Address - Fax:
Practice Address - Street 1:1 S KEENE ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-7199
Practice Address - Country:US
Practice Address - Phone:573-876-8417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-00770363A00000X
MO2014036816363A00000X
IN10001223A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01141687Medicare PIN
INM400028522Medicare PIN
INM400038518Medicare PIN