Provider Demographics
NPI:1902170384
Name:SAMPSON, JENNIFER (BS, CNIM)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SAMPSON
Suffix:
Gender:F
Credentials:BS, CNIM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 SHADOW LAKE DR
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-2593
Mailing Address - Country:US
Mailing Address - Phone:605-222-2716
Mailing Address - Fax:
Practice Address - Street 1:812 AVIS DR
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-9649
Practice Address - Country:US
Practice Address - Phone:734-945-2132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic