Provider Demographics
NPI:1639311285
Name:KROGER, JENNIFER LYNN (LAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:KROGER
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 1:17817 SANTIAGO BLVD
Mailing Address - Street 2:
Mailing Address - City:VILLA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:92861-4133
Mailing Address - Country:US
Mailing Address - Phone:562-328-7699
Mailing Address - Fax:714-998-0084
Practice Address - Street 1:17817 SANTIAGO BLVD
Practice Address - Street 2:
Practice Address - City:VILLA PARK
Practice Address - State:CA
Practice Address - Zip Code:92861-4133
Practice Address - Country:US
Practice Address - Phone:562-328-7699
Practice Address - Fax:714-998-0084
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-28
Last Update Date:2009-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12952171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist