MEDICARE: JESSE D PENNEPACKER

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1992265698
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSE D PENNEPACKER

Provider Business Mailing Address
First Line	:	9390 W LA MADRE WAY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89149-2529
Country	:	US
Telephone Number	:	760-978-7239
Fax Number	:

Provider Business Practice Location Address
First Line	:	9390 W LA MADRE WAY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89149-2529
Country	:	US
Telephone Number	:	760-978-7239
Fax Number	:

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

Provider Enumeration Date	:	03/20/2019
Last Update Date	:	03/20/2019

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