Provider Demographics
NPI:1518390764
Name:WATKINS, JENNIFER SUZANNE (LAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUZANNE
Last Name:WATKINS
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 1:125 CAMBON DR APT 6B
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94132-2506
Mailing Address - Country:US
Mailing Address - Phone:415-452-0233
Mailing Address - Fax:
Practice Address - Street 1:220 MONTGOMERY ST STE 110
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94104-3405
Practice Address - Country:US
Practice Address - Phone:415-828-6463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-12
Last Update Date:2014-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00094900171100000X
NY0049061171100000X
CAAC15408171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist