Provider Demographics
NPI:1386974061
Name:REILLY, JENNIFER M (LAC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:REILLY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11810 INDUSTRIAL CT
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95603-9584
Mailing Address - Country:US
Mailing Address - Phone:530-888-0842
Mailing Address - Fax:530-888-0872
Practice Address - Street 1:11810 INDUSTRIAL CT
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-9584
Practice Address - Country:US
Practice Address - Phone:530-888-0842
Practice Address - Fax:530-888-0872
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-03
Last Update Date:2010-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC8161171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist