Healthcare Provider Details

I. General information

NPI: 1003452285
Provider Name (Legal Business Name): JENNIFER N KUIKEN LPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2019
Last Update Date: 06/29/2020
Certification Date: 06/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2178 JOHNSON AVE
SAN LUIS OBISPO CA
93401-4535
US

IV. Provider business mailing address

2945 MCMILLAN AVE STE 240
SAN LUIS OBISPO CA
93401-6771
US

V. Phone/Fax

Practice location:
  • Phone: 805-781-4712
  • Fax:
Mailing address:
  • Phone: 805-439-4890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT38160
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: