1700138732 NPI number — JENNIFER MICHELLE CRITTENDEN D.P.T

Table of content: JENNIFER MICHELLE CRITTENDEN D.P.T (NPI 1700138732)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700138732 NPI number — JENNIFER MICHELLE CRITTENDEN D.P.T

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRITTENDEN
Provider First Name:
JENNIFER
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.P.T
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LAUCK
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
MICHELLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1700138732
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
480 4TH AVE
Provider Second Line Business Mailing Address:
SUITE 509
Provider Business Mailing Address City Name:
CHULA VISTA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91910-4410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-651-9760
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
480 4TH AVE
Provider Second Line Business Practice Location Address:
SUITE 509
Provider Business Practice Location Address City Name:
CHULA VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91910-4410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-651-9760
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/15/2012

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:  PT 39118 , 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)





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