Provider Demographics
NPI:1639576754
Name:TOM, JENNIFER (LAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:TOM
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 1:1207 CARLSBAD VILLAGE DR
Mailing Address - Street 2:SUITE T
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-1957
Mailing Address - Country:US
Mailing Address - Phone:760-487-8857
Mailing Address - Fax:
Practice Address - Street 1:1207 CARLSBAD VILLAGE DR
Practice Address - Street 2:SUITE T
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-1957
Practice Address - Country:US
Practice Address - Phone:760-487-8857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-04
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16199171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist