Healthcare Provider Details

I. General information

NPI: 1548182181
Provider Name (Legal Business Name): JACQUELYN PONEK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 WEST MALL
ATASCADERO CA
93422-4234
US

IV. Provider business mailing address

4805 SANTA CRUZ RD
ATASCADERO CA
93422-1435
US

V. Phone/Fax

Practice location:
  • Phone: 805-462-4200
  • Fax:
Mailing address:
  • Phone: 805-712-1292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number844548
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: