Provider Demographics
NPI:1407683071
Name:WHITE, JENNIFER MICHAELA
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MICHAELA
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1545 N TEXAS ST STE 201
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-5623
Mailing Address - Country:US
Mailing Address - Phone:510-691-5620
Mailing Address - Fax:
Practice Address - Street 1:1545 N TEXAS ST STE 201
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-5623
Practice Address - Country:US
Practice Address - Phone:510-691-5620
Practice Address - Fax:707-818-1006
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-18
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACPT-02423300246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy