Provider Demographics
NPI:1013436179
Name:BARTLETT, JENNIFER MARIE
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:MARIE
Last Name:BARTLETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42885 WOODSIDE CT
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92544-3369
Mailing Address - Country:US
Mailing Address - Phone:951-775-5332
Mailing Address - Fax:
Practice Address - Street 1:12121 WILSHIRE BLVD STE 1111
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1188
Practice Address - Country:US
Practice Address - Phone:951-775-5332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50653126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA50653Medicaid