MEDICARE: JAY PENNOCK, MD A PROFESSIONAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1114016789
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JAY PENNOCK, MD A PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	1840 41ST AVE STE 102-325
Second Line	:
City	:	CAPITOLA
State	:	CA
Zip	:	95010-2513
Country	:	US
Telephone Number	:	831-345-0652
Fax Number	:

Provider Business Practice Location Address
First Line	:	1595 38TH AVE
Second Line	:
City	:	CAPITOLA
State	:	CA
Zip	:	95010-2901
Country	:	US
Telephone Number	:	831-226-2108
Fax Number	:

Authorized Official
Title or Position	:	OWNER AND PRESIDENT
Name	:	JAY PENNOCK
Credential	:	MD
Telephone Number	:	831-226-2108

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	05/19/2025

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