Provider Demographics
NPI:1437152907
Name:PENNOCK, JAY (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:PENNOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1840 41ST AVE # 102-325
Mailing Address - Street 2:
Mailing Address - City:CAPITOLA
Mailing Address - State:CA
Mailing Address - Zip Code:95010-2513
Mailing Address - Country:US
Mailing Address - Phone:831-345-0652
Mailing Address - Fax:888-258-3926
Practice Address - Street 1:1595 38TH AVE
Practice Address - Street 2:
Practice Address - City:CAPITOLA
Practice Address - State:CA
Practice Address - Zip Code:95010-2901
Practice Address - Country:US
Practice Address - Phone:831-226-2108
Practice Address - Fax:888-258-3926
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77385202D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes202D00000XAllopathic & Osteopathic PhysiciansIntegrative MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG02998Medicare UPIN
CA00G773850Medicare ID - Type Unspecified
CA00G773851Medicare PIN