Provider Demographics
NPI:1174061170
Name:O'DONOVAN, JADE A (AGNP)
Entity type:Individual
Prefix:
First Name:JADE
Middle Name:A
Last Name:O'DONOVAN
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:JADE
Other - Middle Name:A
Other - Last Name:THYNG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:AGNP
Mailing Address - Street 1:789 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03820-2526
Mailing Address - Country:US
Mailing Address - Phone:603-609-6800
Mailing Address - Fax:
Practice Address - Street 1:10 MEMBERS WAY FL 5
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820-5933
Practice Address - Country:US
Practice Address - Phone:603-609-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-09
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH076447-23363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3110543Medicaid