Provider Demographics
NPI:1255696910
Name:PENNYCOOK, JODY LYNN (PA)
Entity type:Individual
Prefix:MISS
First Name:JODY
Middle Name:LYNN
Last Name:PENNYCOOK
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:4740 HOEN AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-7824
Mailing Address - Country:US
Mailing Address - Phone:707-542-2783
Mailing Address - Fax:707-542-7976
Practice Address - Street 1:4740 HOEN AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-7824
Practice Address - Country:US
Practice Address - Phone:707-542-2783
Practice Address - Fax:707-542-7976
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA22225363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical