Provider Demographics
NPI:1851548564
Name:JENNISON, STEPHANIE J (RN,NP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:J
Last Name:JENNISON
Suffix:
Gender:F
Credentials:RN,NP
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:STEVENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:7129 VIA DICHA
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750
Mailing Address - Country:US
Mailing Address - Phone:626-327-3169
Mailing Address - Fax:909-596-2752
Practice Address - Street 1:19191 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-1018
Practice Address - Country:US
Practice Address - Phone:310-354-4346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-25
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP 18240363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health