Provider Demographics
NPI:1093356644
Name:PTAK, JENNIFER ELIZABETH
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELIZABETH
Last Name:PTAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6333 PACIFIC AVE # 261
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-3713
Mailing Address - Country:US
Mailing Address - Phone:209-981-3299
Mailing Address - Fax:
Practice Address - Street 1:6333 PACIFIC AVE # 261
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-3713
Practice Address - Country:US
Practice Address - Phone:209-981-3299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-04
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider