Provider Demographics
NPI:1285199661
Name:PRESTON, JENNIFER A (LAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:PRESTON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3290 VAN BUREN AVE APT 48
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-1240
Mailing Address - Country:US
Mailing Address - Phone:801-644-5576
Mailing Address - Fax:
Practice Address - Street 1:3290 VAN BUREN AVE APT 48
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-1240
Practice Address - Country:US
Practice Address - Phone:801-644-5576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-09
Last Update Date:2019-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11055212-1201171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist