Healthcare Provider Details

I. General information

NPI: 1649738808
Provider Name (Legal Business Name): JENNIFER CIPOLLONE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2019
Last Update Date: 03/30/2022
Certification Date: 03/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 CALLE AMANECER
SAN CLEMENTE CA
92673-6214
US

IV. Provider business mailing address

24312 TIMOTHY DR
DANA POINT CA
92629-1069
US

V. Phone/Fax

Practice location:
  • Phone: 949-481-9113
  • Fax:
Mailing address:
  • Phone: 650-946-7026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberD4319040
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: