=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710476197
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW JARROD JENNINGS PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2018
-----------------------------------------------------
Last Update Date | 05/01/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1501 HELEN POWER DR
-----------------------------------------------------
City | VACAVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95687-3351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-451-1396
-----------------------------------------------------
Fax | 707-451-4857
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 721 WEBSTER ST
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94117-1715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-300-6237
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 75390
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------