Healthcare Provider Details

I. General information

NPI: 1245776244
Provider Name (Legal Business Name): JENNIFER LAUREN LANE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2017
Last Update Date: 02/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2876 SYCAMORE DR
SIMI VALLEY CA
93065-1530
US

IV. Provider business mailing address

20516 GERMAIN ST
CHATSWORTH CA
91311-2417
US

V. Phone/Fax

Practice location:
  • Phone: 805-527-6424
  • Fax:
Mailing address:
  • Phone: 951-750-9051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number54157
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: