Basic Information
| Provider Information | |||||||||
| NPI: | 1821121641 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITELEY | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | ADELE | ||||||||
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| Credential: | CAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2838 SCHNELL SCHOOL RD APT 30 | ||||||||
| Address2: | |||||||||
| City: | PLACERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956674953 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306224359 | ||||||||
| FaxNumber: | 5303331019 | ||||||||
| Practice Location | |||||||||
| Address1: | 5607 MT. MURPHY RD. | ||||||||
| Address2: | |||||||||
| City: | GARDEN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5303339460 | ||||||||
| FaxNumber: | 5303331019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 03-067230 | CA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 03-067230 | 01 | CA | CAS | OTHER |