Provider Demographics
NPI:1043533870
Name:JENNIFER PACK, NURSE PRACTITIONER, APC
Entity Type:Organization
Organization Name:JENNIFER PACK, NURSE PRACTITIONER, APC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:PACK
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:858-485-8022
Mailing Address - Street 1:15706 POMERADO RD
Mailing Address - Street 2:SUITE S 206
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-2067
Mailing Address - Country:US
Mailing Address - Phone:858-485-8022
Mailing Address - Fax:858-815-6820
Practice Address - Street 1:15706 POMERADO RD
Practice Address - Street 2:SUITE S 206
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2067
Practice Address - Country:US
Practice Address - Phone:858-485-8022
Practice Address - Fax:858-815-6820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-08
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11906363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty