Provider Demographics
NPI:1114008422
Name:PITTS, JACQUELINE L (CRNA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:L
Last Name:PITTS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1834 STONE AVE
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95125-1306
Mailing Address - Country:US
Mailing Address - Phone:408-995-0102
Mailing Address - Fax:408-995-0190
Practice Address - Street 1:1895 MOWRY AVE
Practice Address - Street 2:SUITE 116
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1737
Practice Address - Country:US
Practice Address - Phone:510-792-3398
Practice Address - Fax:510-792-3951
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN395303367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN3953030Medicaid