Provider Demographics
NPI:1831923671
Name:VICTORIO, JENNIFER
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:VICTORIO
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 1:994 LIGHTHOUSE WAY
Mailing Address - Street 2:
Mailing Address - City:PORT HUENEME
Mailing Address - State:CA
Mailing Address - Zip Code:93041-3532
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1900 LAKE TAHOE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-6305
Practice Address - Country:US
Practice Address - Phone:530-573-7970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program