Provider Demographics
NPI:1386741072
Name:REIFENBERGER, JODY L (PA)
Entity type:Individual
Prefix:MRS
First Name:JODY
Middle Name:L
Last Name:REIFENBERGER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JODY
Other - Middle Name:LOUISE
Other - Last Name:FARREY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C, MMS
Mailing Address - Street 1:150 VALPREDA RD
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069-2973
Mailing Address - Country:US
Mailing Address - Phone:760-736-6700
Mailing Address - Fax:
Practice Address - Street 1:150 VALPREDA RD
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069-2973
Practice Address - Country:US
Practice Address - Phone:760-736-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002183363A00000X
CA22669364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085002183Medicaid
Q22953Medicare UPIN
ILK09235Medicare ID - Type Unspecified