Provider Demographics
NPI:1780607564
Name:LAND, JENNAFER LEE (DC)
Entity type:Individual
Prefix:DR
First Name:JENNAFER
Middle Name:LEE
Last Name:LAND
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:JENNAFER
Other - Middle Name:LEE
Other - Last Name:RIVETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:1269 PLEASANT GROVE BLVD
Mailing Address - Street 2:SUITE 190
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-5858
Mailing Address - Country:US
Mailing Address - Phone:916-787-0808
Mailing Address - Fax:916-787-1060
Practice Address - Street 1:1269 PLEASANT GROVE BLVD
Practice Address - Street 2:SUITE 190
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95747-5858
Practice Address - Country:US
Practice Address - Phone:916-787-0808
Practice Address - Fax:916-787-1060
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC29090111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0290900Medicare ID - Type Unspecified
CAU99770Medicare UPIN