Provider Demographics
NPI:1134780836
Name:VAN WORMER, JENNIFER C
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:C
Last Name:VAN WORMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 E OAK ST
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-3610
Mailing Address - Country:US
Mailing Address - Phone:707-345-4012
Mailing Address - Fax:844-388-6167
Practice Address - Street 1:137 E OAK ST
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-3610
Practice Address - Country:US
Practice Address - Phone:707-345-4012
Practice Address - Fax:844-388-6167
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator