Provider Demographics
NPI:1174261796
Name:KIPETZ, JENNA LEIGH (MED, ATC)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:LEIGH
Last Name:KIPETZ
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Gender:F
Credentials:MED, ATC
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:7831 SPINNAKER BAY DR UNIT 207
Mailing Address - Street 2:
Mailing Address - City:SHERRILLS FORD
Mailing Address - State:NC
Mailing Address - Zip Code:28673-9291
Mailing Address - Country:US
Mailing Address - Phone:860-462-1434
Mailing Address - Fax:
Practice Address - Street 1:35000 GUADALCANAL ST BLDG 573
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92140-5599
Practice Address - Country:US
Practice Address - Phone:619-524-8313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-24
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer