Provider Demographics
NPI:1649574138
Name:BURNETT, JENNIFFER ANN
Entity type:Individual
Prefix:
First Name:JENNIFFER
Middle Name:ANN
Last Name:BURNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2914 COLD SPRINGS RD STE B
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-4237
Mailing Address - Country:US
Mailing Address - Phone:530-626-9240
Mailing Address - Fax:530-626-8992
Practice Address - Street 1:2914 COLD SPRINGS RD STE B
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-4237
Practice Address - Country:US
Practice Address - Phone:530-626-9240
Practice Address - Fax:530-626-8992
Is Sole Proprietor?:No
Enumeration Date:2010-12-27
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9943174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist