=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821881830
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAY PENNOCK MEDICAL DIRECTOR PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2025
-----------------------------------------------------
Last Update Date | 05/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 901 SOQUEL AVE STE A
-----------------------------------------------------
City | SANTA CRUZ
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95062-2122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-345-0652
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1840 41ST AVE # 102-325
-----------------------------------------------------
City | CAPITOLA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95010-2513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-345-0652
-----------------------------------------------------
Fax | 888-258-3926
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER AND PRESIDENT
-----------------------------------------------------
Name | JAY PENNOCK
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 831-345-0652
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------