Basic Information
| Provider Information | |||||||||
| NPI: | 1922597632 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCDANIEL | ||||||||
| FirstName: | JENNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2529 24TH ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941103508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6502604670 | ||||||||
| FaxNumber: | 4155206530 | ||||||||
| Practice Location | |||||||||
| Address1: | 2529 24TH ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941103508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6502604670 | ||||||||
| FaxNumber: | 4155206530 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2018 | ||||||||
| LastUpdateDate: | 05/08/2018 | ||||||||
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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 | 106S00000X | 17-36975 | CA | Y |
No ID Information.