Provider Demographics
NPI:1902299811
Name:PROFFITT, JENNIFER NICOLE
Entity type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:NICOLE
Last Name:PROFFITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:NICOLE
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 THE CITY DR S # ZC4482
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3201
Mailing Address - Country:US
Mailing Address - Phone:714-456-5837
Mailing Address - Fax:
Practice Address - Street 1:320 S WAKARA WAY
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1214
Practice Address - Country:US
Practice Address - Phone:800-469-7423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-17
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
CAGC000646170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program