1538560008 NPI number — JENNIFER LAURA DEAGON

Table of content: JENNIFER LAURA DEAGON (NPI 1538560008)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538560008 NPI number — JENNIFER LAURA DEAGON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEAGON
Provider First Name:
JENNIFER
Provider Middle Name:
LAURA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538560008
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1083
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEN LOMOND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95005-2045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
831-454-4969
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 EMELINE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA CRUZ
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95060-1976
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-466-8977
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/15/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LCSW107884 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YM0800X , with the licence number: ASW68018 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)