Healthcare Provider Details

I. General information

NPI: 1205893666
Provider Name (Legal Business Name): JENNIFER D. FORTHMAN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 10/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 W E ST
TEHACHAPI CA
93561-1607
US

IV. Provider business mailing address

105 W E ST PO BOX 1900
TEHACHAPI CA
93561-1607
US

V. Phone/Fax

Practice location:
  • Phone: 661-823-7070
  • Fax:
Mailing address:
  • Phone: 661-823-7070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1523
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number22143
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: