Provider Demographics
NPI:1740471382
Name:FLYNN, JENNIFER LEIGH
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEIGH
Last Name:FLYNN
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 1:1685 SHAFFER RD
Mailing Address - Street 2:
Mailing Address - City:ATWATER
Mailing Address - State:CA
Mailing Address - Zip Code:95301-4456
Mailing Address - Country:US
Mailing Address - Phone:209-357-3420
Mailing Address - Fax:209-357-0904
Practice Address - Street 1:1685 SHAFFER RD
Practice Address - Street 2:
Practice Address - City:ATWATER
Practice Address - State:CA
Practice Address - Zip Code:95301-4456
Practice Address - Country:US
Practice Address - Phone:209-357-3420
Practice Address - Fax:209-357-0904
Is Sole Proprietor?:No
Enumeration Date:2007-08-08
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33880225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA555244Medicare Oscar/Certification