Healthcare Provider Details

I. General information

NPI: 1295199263
Provider Name (Legal Business Name): JACOB CARPENTER FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2016
Last Update Date: 07/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45104 10TH ST W
LANCASTER CA
93534-2310
US

IV. Provider business mailing address

45104 10TH ST W
LANCASTER CA
93534-2310
US

V. Phone/Fax

Practice location:
  • Phone: 661-942-2391
  • Fax:
Mailing address:
  • Phone: 661-942-2391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95004394
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: