Provider Demographics
NPI:1083179287
Name:SANBORN, JENNA REBEKAH (LAC, MSTOM)
Entity Type:Individual
Prefix:MS
First Name:JENNA
Middle Name:REBEKAH
Last Name:SANBORN
Suffix:
Gender:F
Credentials:LAC, MSTOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1949 MORENA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3554
Mailing Address - Country:US
Mailing Address - Phone:619-622-5668
Mailing Address - Fax:
Practice Address - Street 1:3934 MURPHY CANYON RD STE B104
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4425
Practice Address - Country:US
Practice Address - Phone:619-622-5668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-01
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16902171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist