Provider Demographics
NPI:1114008554
Name:MALLOY, JENNIFER REBECCA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:REBECCA
Last Name:MALLOY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2255 S BASCOM AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-7800
Mailing Address - Country:US
Mailing Address - Phone:408-376-3626
Mailing Address - Fax:408-871-2377
Practice Address - Street 1:2255 S BASCOM AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-7800
Practice Address - Country:US
Practice Address - Phone:408-376-3626
Practice Address - Fax:408-871-2377
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA17849363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ60782Medicare UPIN