Healthcare Provider Details

I. General information

NPI: 1053750836
Provider Name (Legal Business Name): JENNIFER KANGAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2013
Last Update Date: 07/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2442 IOWA AVENUE APT. E6
RIVERSIDE CA
92507
US

IV. Provider business mailing address

2442 IOWA AVE APT. E6
SAN BERNARDINO CA
92415-0001
US

V. Phone/Fax

Practice location:
  • Phone: 951-505-2706
  • Fax:
Mailing address:
  • Phone: 909-252-4010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: