Healthcare Provider Details

I. General information

NPI: 1154904589
Provider Name (Legal Business Name): JENNIFER MARIE ANTOINE DACM, L.AC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2021
Last Update Date: 05/03/2021
Certification Date: 05/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15708 POMERADO RD STE N-203
POWAY CA
92064-2066
US

IV. Provider business mailing address

15708 POMERADO RD STE N-203
POWAY CA
92064-2066
US

V. Phone/Fax

Practice location:
  • Phone: 843-597-1139
  • Fax:
Mailing address:
  • Phone: 843-597-1139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number19113
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: