Provider Demographics
NPI:1508154253
Name:PENCE, JAMIE L
Entity Type:Individual
Prefix:MS
First Name:JAMIE
Middle Name:L
Last Name:PENCE
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 1:27468 DIANE MARIE CIR
Mailing Address - Street 2:
Mailing Address - City:SAUGUS
Mailing Address - State:CA
Mailing Address - Zip Code:91350-1778
Mailing Address - Country:US
Mailing Address - Phone:661-263-2505
Mailing Address - Fax:
Practice Address - Street 1:27468 DIANE MARIE CIR
Practice Address - Street 2:
Practice Address - City:SAUGUS
Practice Address - State:CA
Practice Address - Zip Code:91350-1778
Practice Address - Country:US
Practice Address - Phone:661-263-2505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-15
Last Update Date:2011-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6240225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6240Medicaid
CA6240Medicaid