Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363L00000X | Nurse Practitioner | 95008823 | CA |
Y | 363LP2300X | Nurse Practitioner - Primary Care | NP95008823 | CA |
NPI | 1083103956 |
---|---|
Provider Name | Jeffensen Jay Timacdog |
First Address | Chula Vista, CA 91911-3131 |
Second Address | El Segundo, CA 90245-4705 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/05/2018 |
Last Update Date | 24/02/2021 |