Provider Demographics
NPI:1659808376
Name:LUCATERO, JENNIFER ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:LUCATERO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ANN
Other - Last Name:KNAPPE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1777 BENEDICT WAY
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-3505
Mailing Address - Country:US
Mailing Address - Phone:510-402-9246
Mailing Address - Fax:
Practice Address - Street 1:9041 MAGNOLIA AVE STE 206
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3956
Practice Address - Country:US
Practice Address - Phone:951-354-2220
Practice Address - Fax:951-354-2218
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2019-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA54823363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant