Provider Demographics
NPI:1386972552
Name:PERALTA, JENNIFER (MT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PERALTA
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2171 JUNIPERO SERRA BLVD STE 590
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94014-1990
Mailing Address - Country:US
Mailing Address - Phone:650-756-9003
Mailing Address - Fax:650-756-9005
Practice Address - Street 1:2171 JUNIPERO SERRA BLVD STE 590
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94014-1990
Practice Address - Country:US
Practice Address - Phone:650-756-9003
Practice Address - Fax:650-756-9005
Is Sole Proprietor?:No
Enumeration Date:2009-11-30
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist