Provider Demographics
NPI:1043859382
Name:MASON, JENNIFER SUELAN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUELAN
Last Name:MASON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:SUELAN
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:3293 MCKINLEY ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-4716
Mailing Address - Country:US
Mailing Address - Phone:619-341-4288
Mailing Address - Fax:
Practice Address - Street 1:3293 MCKINLEY ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-4716
Practice Address - Country:US
Practice Address - Phone:619-341-4288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-03
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC8685171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty