Provider Demographics
NPI:1417492935
Name:PUTNEY, JENNIFER (RDA)
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:
Last Name:PUTNEY
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5814 NECTAR AVE
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92544-4552
Mailing Address - Country:US
Mailing Address - Phone:951-426-3534
Mailing Address - Fax:
Practice Address - Street 1:5814 NECTAR AVE
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92544-4552
Practice Address - Country:US
Practice Address - Phone:951-426-3534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDA73563126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARDA73563Medicaid