Provider Demographics
NPI:1174272025
Name:TIPTON, JEN (MED)
Entity Type:Individual
Prefix:
First Name:JEN
Middle Name:
Last Name:TIPTON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 CAMINITO MADRIGAL UNIT A
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92011-2452
Mailing Address - Country:US
Mailing Address - Phone:818-427-4237
Mailing Address - Fax:
Practice Address - Street 1:907 CAMINITO MADRIGAL UNIT A
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92011-2452
Practice Address - Country:US
Practice Address - Phone:818-427-4237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-19
Last Update Date:2022-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 174400000X, 175T00000X
CA171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171400000XOther Service ProvidersHealth & Wellness CoachGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No174400000XOther Service ProvidersSpecialist
No175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty