Provider Demographics
NPI:1194826859
Name:LOUCKS, JENNIFER ANN (DC, QME)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ANN
Last Name:LOUCKS
Suffix:
Gender:F
Credentials:DC, QME
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1080A HOLLY ST
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-2536
Mailing Address - Country:US
Mailing Address - Phone:650-593-1103
Mailing Address - Fax:650-593-1104
Practice Address - Street 1:1080A HOLLY ST
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-2536
Practice Address - Country:US
Practice Address - Phone:650-593-1103
Practice Address - Fax:650-593-1104
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC23988111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADCO23988Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID