Provider Demographics
NPI:1083929541
Name:HENNICK, JENNIFER LOUISE (FNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LOUISE
Last Name:HENNICK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:THROCKMORTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:575 N THOMPSON RD
Mailing Address - Street 2:
Mailing Address - City:TIPTON
Mailing Address - State:CA
Mailing Address - Zip Code:93272-9756
Mailing Address - Country:US
Mailing Address - Phone:559-752-4147
Mailing Address - Fax:559-752-4150
Practice Address - Street 1:575 N THOMPSON RD
Practice Address - Street 2:
Practice Address - City:TIPTON
Practice Address - State:CA
Practice Address - Zip Code:93272-9756
Practice Address - Country:US
Practice Address - Phone:559-752-4147
Practice Address - Fax:559-752-4150
Is Sole Proprietor?:No
Enumeration Date:2010-08-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19991363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMH2440220OtherDEA #