Provider Demographics
NPI:1073579231
Name:JET, JENNIE (MD)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:JET
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:916-379-2915
Mailing Address - Fax:
Practice Address - Street 1:1595 SOQUEL DR
Practice Address - Street 2:STE 110
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1719
Practice Address - Country:US
Practice Address - Phone:831-462-9955
Practice Address - Fax:831-462-4488
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG86051208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G860510Medicaid
250012704Medicare PIN
CA00G860510Medicare PIN
CAG60499Medicare UPIN