Provider Demographics
NPI:1376780296
Name:PONDER- PETERS, JENNIFER LOUISE
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LOUISE
Last Name:PONDER- PETERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 W. RAMSEY
Mailing Address - Street 2:STE 100
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220
Mailing Address - Country:US
Mailing Address - Phone:951-849-7142
Mailing Address - Fax:951-849-1762
Practice Address - Street 1:1330 W. RAMSEY
Practice Address - Street 2:STE 100
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220
Practice Address - Country:US
Practice Address - Phone:951-849-7142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-14
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33478167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician