Provider Demographics
NPI:1790035046
Name:TA, JENNIFER (CPNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:TA
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:338 S DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93437-6307
Mailing Address - Country:US
Mailing Address - Phone:805-605-1301
Mailing Address - Fax:
Practice Address - Street 1:338 S DAKOTA AVE BLDG 13850
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93437-6307
Practice Address - Country:US
Practice Address - Phone:805-606-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-13
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19921363LP2300X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care