Healthcare Provider Details

I. General information

NPI: 1649942467
Provider Name (Legal Business Name): JENNIFER WARD PUCCI NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2021
Last Update Date: 10/08/2021
Certification Date: 10/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4077 5TH AVE
SAN DIEGO CA
92103-2105
US

IV. Provider business mailing address

302 WASHINGTON ST # 844
SAN DIEGO CA
92103-2110
US

V. Phone/Fax

Practice location:
  • Phone: 619-686-3800
  • Fax:
Mailing address:
  • Phone: 619-203-7190
  • Fax: 858-675-0508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95018543
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: