Basic Information
Provider Information | |||||||||
NPI: | 1386741072 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | REIFENBERGER | ||||||||
FirstName: | JODY | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FARREY | ||||||||
OtherFirstName: | JODY | ||||||||
OtherMiddleName: | LOUISE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C, MMS | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 150 VALPREDA RD | ||||||||
Address2: |   | ||||||||
City: | SAN MARCOS | ||||||||
State: | CA | ||||||||
PostalCode: | 920692973 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7607366700 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 150 VALPREDA RD | ||||||||
Address2: |   | ||||||||
City: | SAN MARCOS | ||||||||
State: | CA | ||||||||
PostalCode: | 920692973 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7607366700 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/17/2006 | ||||||||
LastUpdateDate: | 02/26/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085002183 | IL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 364SF0001X | 22669 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Family Health |
ID Information
ID | Type | State | Issuer | Description | 085002183 | 05 | IL |   | MEDICAID |