Provider Demographics
NPI:1407518269
Name:PRINCE, JEANETTE ANN
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:ANN
Last Name:PRINCE
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 1:1741 LANDSFORD ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93535-1150
Mailing Address - Country:US
Mailing Address - Phone:661-917-5322
Mailing Address - Fax:
Practice Address - Street 1:830 W AVENUE L STE 109
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-7207
Practice Address - Country:US
Practice Address - Phone:661-902-1793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-08
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL9516174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist