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General NPI Number Information
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NPI Number | 1114016789
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Entity Type | Organization
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Legal Business Name | JAY PENNOCK, MD A PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 10/12/2006
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Last Update Date | 05/19/2025
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Provider Practice Location Address
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Address Line | 1595 38TH AVE
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City | CAPITOLA
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State | CA
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Zip | 95010-2901
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Country | US
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Telephone | 831-226-2108
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Fax |
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Provider Business Mailing Address
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Address Line | 1840 41ST AVE STE 102-325
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City | CAPITOLA
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State | CA
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Zip | 95010-2513
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Country | US
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Telephone | 831-345-0652
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Fax |
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Authorized Official
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Title or Position | OWNER AND PRESIDENT
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Name | JAY PENNOCK
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Credential | MD
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Telephone | 831-226-2108
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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