Basic Information
| Provider Information | |||||||||
| NPI: | 1861543308 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 265 POSADA LN | ||||||||
| Address2: | SUITE B | ||||||||
| City: | TEMPLETON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934654056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054340900 | ||||||||
| FaxNumber: | 8054349260 | ||||||||
| Practice Location | |||||||||
| Address1: | 265 POSADA LN | ||||||||
| Address2: | SUITE B | ||||||||
| City: | TEMPLETON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934654056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054340900 | ||||||||
| FaxNumber: | 8054349260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2007 | ||||||||
| LastUpdateDate: | 02/25/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 13473 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1028535 | 01 | NCCPA CERTIFICATION | OTHER | PA13473 | 01 | CA | STATE PHYSICIAN ASSISTANT LICENSE | OTHER | CS813Z | 01 | CA | MEDICARE PART B PTAN NUMBER- PALMETTO GBA | OTHER |