Healthcare Provider Details

I. General information

NPI: 1144319278
Provider Name (Legal Business Name): JENNIFER M GAULT PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 E HERNDON AVE
FRESNO CA
93720-3391
US

IV. Provider business mailing address

1630 E HERNDON AVE
FRESNO CA
93720-3391
US

V. Phone/Fax

Practice location:
  • Phone: 559-256-5200
  • Fax: 559-256-5376
Mailing address:
  • Phone: 559-256-5200
  • Fax: 559-256-5376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA17787
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: