Healthcare Provider Details

I. General information

NPI: 1598253353
Provider Name (Legal Business Name): JENNIFER RENEE LUMMUS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2018
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3614 CONDO COURT
SANTA ROSA CA
95403
US

IV. Provider business mailing address

639 AVALON AVE
SANTA ROSA CA
95407-7224
US

V. Phone/Fax

Practice location:
  • Phone: 707-360-1913
  • Fax: 707-360-1923
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: