Basic Information
Provider Information
NPI: 1003004474
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PETTIBONE
FirstName: JENNIFER
MiddleName: RUTH
NamePrefix: MS.
NameSuffix:  
Credential: RN
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1048 2ND ST APT 6
Address2:  
City: NOVATO
State: CA
PostalCode: 949452439
CountryCode: US
TelephoneNumber: 4158971899
FaxNumber:  
Practice Location
Address1: 2101 COURAGE DR
Address2: MS-10-200
City: FAIRFIELD
State: CA
PostalCode: 945336717
CountryCode: US
TelephoneNumber: 7077842154
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/10/2007
LastUpdateDate: 10/10/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
163WP0808X464317CAY Nursing Service ProvidersRegistered NursePsych/Mental Health

No ID Information.


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