Healthcare Provider Details

I. General information

NPI: 1376780296
Provider Name (Legal Business Name): MRS. JENNIFER LOUISE PONDER- PETERS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2009
Last Update Date: 01/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 W. RAMSEY STE 100
BANNING CA
92220
US

IV. Provider business mailing address

1330 W. RAMSEY STE 100
BANNING CA
92220
US

V. Phone/Fax

Practice location:
  • Phone: 951-849-7142
  • Fax:
Mailing address:
  • Phone: 951-849-7142
  • Fax: 951-849-1762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number33478
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: