Provider Demographics
NPI:1639475254
Name:GUSTAFSON, JENNIFER LEE (NP)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LEE
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2767 OLIVE HWY
Mailing Address - Street 2:
Mailing Address - City:OROVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95966-6118
Mailing Address - Country:US
Mailing Address - Phone:530-533-8500
Mailing Address - Fax:530-538-3277
Practice Address - Street 1:2767 OLIVE HWY
Practice Address - Street 2:
Practice Address - City:OROVILLE
Practice Address - State:CA
Practice Address - Zip Code:95966-6118
Practice Address - Country:US
Practice Address - Phone:530-533-8500
Practice Address - Fax:530-538-3277
Is Sole Proprietor?:No
Enumeration Date:2011-01-28
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP19069363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care