Basic Information
Provider Information | |||||||||
NPI: | 1821343757 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROCHA | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | ARLENE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MILLS | ||||||||
OtherFirstName: | JENNIFER | ||||||||
OtherMiddleName: | ARLENE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 504 PLAZA DR | ||||||||
Address2: |   | ||||||||
City: | SANTA MARIA | ||||||||
State: | CA | ||||||||
PostalCode: | 934546917 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8057393474 | ||||||||
FaxNumber: | 8053463548 | ||||||||
Practice Location | |||||||||
Address1: | 877 OAK PARK BLVD | ||||||||
Address2: |   | ||||||||
City: | PISMO BEACH | ||||||||
State: | CA | ||||||||
PostalCode: | 934493292 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8054748450 | ||||||||
FaxNumber: | 8054748454 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/17/2012 | ||||||||
LastUpdateDate: | 06/10/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA22367 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 1104509 | 01 |   | NATIONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANTS | OTHER | PA22367 | 01 | CA | CALIFORNIA STATE LICENSE | OTHER |