Provider Demographics
NPI:1841232576
Name:HALES, JENNIFER LYNN WOOLSEY (PAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN WOOLSEY
Last Name:HALES
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:WOOLSEY HALES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:PO BOX 660476
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91066-0476
Mailing Address - Country:US
Mailing Address - Phone:626-447-0296
Mailing Address - Fax:
Practice Address - Street 1:3800 JANES RD
Practice Address - Street 2:
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-4742
Practice Address - Country:US
Practice Address - Phone:707-826-8264
Practice Address - Fax:707-826-8292
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15908363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA15908Medicaid
CAPA15908Medicaid
CAQ33942Medicare UPIN
CABQ161YMedicare PIN