MEDICARE: JENNIFER C. DE'LAVIGNE RDHAP

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	124Q00000X	Dental Hygienist	915	CA

General Provider Information

NPI Number	:	1770281628
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER C. DE'LAVIGNE RDHAP

Provider Business Mailing Address
First Line	:	203 E PINE ST
Second Line	:
City	:	FORT BRAGG
State	:	CA
Zip	:	95437-3306
Country	:	US
Telephone Number	:	707-962-8044
Fax Number	:

Provider Business Practice Location Address
First Line	:	203 E PINE ST
Second Line	:
City	:	FORT BRAGG
State	:	CA
Zip	:	95437-3306
Country	:	US
Telephone Number	:	707-962-8044
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/20/2023
Last Update Date	:	02/20/2023

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