Healthcare Provider Details

I. General information

NPI: 1255368775
Provider Name (Legal Business Name): JENNIFER MARIE MOFFITT L.AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2810 CAMINO DEL RIO S #102
SAN DIEGO CA
92108-3818
US

IV. Provider business mailing address

2810 CAMINO DEL RIO S #102
SAN DIEGO CA
92108-3818
US

V. Phone/Fax

Practice location:
  • Phone: 619-688-0061
  • Fax: 619-688-0026
Mailing address:
  • Phone: 619-688-0061
  • Fax: 619-688-0026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC 8951
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: