Provider Demographics
NPI:1861543308
Name:KING, JENNIFER L (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:KING
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 POSADA LN
Mailing Address - Street 2:SUITE B
Mailing Address - City:TEMPLETON
Mailing Address - State:CA
Mailing Address - Zip Code:93465-4056
Mailing Address - Country:US
Mailing Address - Phone:805-434-0900
Mailing Address - Fax:805-434-9260
Practice Address - Street 1:265 POSADA LN
Practice Address - Street 2:SUITE B
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-4056
Practice Address - Country:US
Practice Address - Phone:805-434-0900
Practice Address - Fax:805-434-9260
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13473363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1028535OtherNCCPA CERTIFICATION
CAPA13473OtherSTATE PHYSICIAN ASSISTANT LICENSE
CACS813ZOtherMEDICARE PART B PTAN NUMBER- PALMETTO GBA