Healthcare Provider Details

I. General information

NPI: 1700808094
Provider Name (Legal Business Name): JENNIFER JILL NUCKTON M.P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 LOMA ALTA ROAD
CARMEL CA
93923
US

IV. Provider business mailing address

774 OAK STREET
MONTEREY CA
93940
US

V. Phone/Fax

Practice location:
  • Phone: 831-655-1554
  • Fax:
Mailing address:
  • Phone: 831-646-1764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number19640
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: