Provider Demographics
NPI:1821121641
Name:WHITELEY, JENNIFER ADELE (CAS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ADELE
Last Name:WHITELEY
Suffix:
Gender:F
Credentials:CAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2838 SCHNELL SCHOOL RD APT 30
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-4953
Mailing Address - Country:US
Mailing Address - Phone:530-622-4359
Mailing Address - Fax:530-333-1019
Practice Address - Street 1:5607 MT. MURPHY RD.
Practice Address - Street 2:
Practice Address - City:GARDEN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95633
Practice Address - Country:US
Practice Address - Phone:530-333-9460
Practice Address - Fax:530-333-1019
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA03-067230174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA03-067230OtherCAS