Provider Demographics
NPI:1215250139
Name:GAINES, JENNIE MARQUITTA (MLT)
Entity type:Individual
Prefix:
First Name:JENNIE
Middle Name:MARQUITTA
Last Name:GAINES
Suffix:
Gender:F
Credentials:MLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8760 REDWOOD DR UNIT 141
Mailing Address - Street 2:
Mailing Address - City:SANTEE
Mailing Address - State:CA
Mailing Address - Zip Code:92071-7713
Mailing Address - Country:US
Mailing Address - Phone:619-592-4539
Mailing Address - Fax:
Practice Address - Street 1:8760 REDWOOD DR UNIT 141
Practice Address - Street 2:
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-7713
Practice Address - Country:US
Practice Address - Phone:619-592-4539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-05
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300105246RM2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical Laboratory