Provider Demographics
NPI:1245776244
Name:LANE, JENNIFER LAUREN (PA)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LAUREN
Last Name:LANE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20516 GERMAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:CA
Mailing Address - Zip Code:91311-2417
Mailing Address - Country:US
Mailing Address - Phone:951-750-9051
Mailing Address - Fax:
Practice Address - Street 1:2876 SYCAMORE DR
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1530
Practice Address - Country:US
Practice Address - Phone:805-527-6424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-13
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54157363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical