Healthcare Provider Details

I. General information

NPI: 1265786362
Provider Name (Legal Business Name): JENNIFER LYNN ANDERSON RN, BSN, PHN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2012
Last Update Date: 01/19/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 J STREET STE 100
SACRAMENTO CA
95819
US

IV. Provider business mailing address

6000 J ST
SACRAMENTO CA
95819-6000
US

V. Phone/Fax

Practice location:
  • Phone: 916-278-4106
  • Fax:
Mailing address:
  • Phone: 916-278-4106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number791752
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number791752
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: