1326164625 NPI number — MS. JESSICA FEENEY M.F.T.I.

Table of content: MS. JESSICA FEENEY M.F.T.I. (NPI 1326164625)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326164625 NPI number — MS. JESSICA FEENEY M.F.T.I.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FEENEY
Provider First Name:
JESSICA
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
M.F.T.I.
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:
1326164625
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
555 ELYSIAN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENNGROVE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94951-8618
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-971-9205
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 COLLEGE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA ROSA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95404-3908
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-568-2300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/21/2007

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: 106H00000X , with the licence number:  IMF46462 , 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: 021273900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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