1740388297 NPI number — JENNIFER L GUTIERREZ MSPT

Table of content: JENNIFER L GUTIERREZ MSPT (NPI 1740388297)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740388297 NPI number — JENNIFER L GUTIERREZ MSPT

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JOHNSTON
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1740388297
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/31/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
525 E CHARLESTON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALO ALTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94306-4247
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-618-3360
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
68 WILLOW RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MENLO PARK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94025-3653
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-390-6659
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/20/2006

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: 225100000X , with the licence number:  PT00007873 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT41011 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8936908 . This is a "CRIME VICTIMS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 159304 . This is a "DEPT OF LABOR & INDUSTRIE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8972GU . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 650024224 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: A010 . This is a "TRICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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