Healthcare Provider Details

I. General information

NPI: 1992205124
Provider Name (Legal Business Name): JENNIFER MADANAT LM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2018
Last Update Date: 02/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 CRENSHAW CT
PACIFICA CA
94044-1060
US

IV. Provider business mailing address

115 CRENSHAW CT
PACIFICA CA
94044-1060
US

V. Phone/Fax

Practice location:
  • Phone: 415-519-3734
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number527
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: