Provider Demographics
NPI:1770513616
Name:HATZKILSON, JENNIFER A (MA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:HATZKILSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5192 CHABLIS CIR
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-3168
Mailing Address - Country:US
Mailing Address - Phone:949-250-9695
Mailing Address - Fax:
Practice Address - Street 1:62 CORPORATE PARK
Practice Address - Street 2:SUITE 112
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92606-3122
Practice Address - Country:US
Practice Address - Phone:949-250-9695
Practice Address - Fax:949-250-9698
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU1235231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAU1235OtherAUDIOLOGY STATE LICENCE
CAAU0012350Medicaid
CAHA4149OtherHEARING AID DISPENSING
CAAUD1235Medicare ID - Type UnspecifiedAUDIOLOGY