Healthcare Provider Details

I. General information

NPI: 1417130147
Provider Name (Legal Business Name): JENNIE AUFHAUSER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2007
Last Update Date: 10/25/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 SANTA MONICA BLVD STE 480W
SANTA MONICA CA
90404-2121
US

IV. Provider business mailing address

2001 SANTA MONICA BLVD STE 480W
SANTA MONICA CA
90404-2121
US

V. Phone/Fax

Practice location:
  • Phone: 310-954-9501
  • Fax: 310-954-9502
Mailing address:
  • Phone: 310-954-9501
  • Fax: 310-954-9502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberPA19475
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA19475
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: