Basic Information
| Provider Information | |||||||||
| NPI: | 1821054446 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PENDLETON | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | JOY | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 603725 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282603725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285752625 | ||||||||
| FaxNumber: | 8283502174 | ||||||||
| Practice Location | |||||||||
| Address1: | 2655 CAMINO DEL RIO N STE 425 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921081633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192866687 | ||||||||
| FaxNumber: | 6192866695 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2006 | ||||||||
| LastUpdateDate: | 04/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | A80748 | CA | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 00A8074800 | 05 | CA | MEDICAID | GW221Z | 01 | CA | MEDICARE PTAN | OTHER |