Provider Demographics
NPI:1316951460
Name:MCLEAN-MADERA, JENNIFER (NP,PHN,RN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MCLEAN-MADERA
Suffix:
Gender:F
Credentials:NP,PHN,RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93101-1606
Mailing Address - Country:US
Mailing Address - Phone:805-963-2445
Mailing Address - Fax:805-965-6052
Practice Address - Street 1:1200 W HILLCREST DR
Practice Address - Street 2:STE. 100
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91320-2734
Practice Address - Country:US
Practice Address - Phone:805-963-2445
Practice Address - Fax:805-965-2292
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA457700363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA457700Medicaid
CA457700Medicaid