Provider Demographics
NPI:1033485131
Name:DONOSO, JENNA RENEE (DO)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:RENEE
Last Name:DONOSO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 W MISSISSIPPI AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-6110
Mailing Address - Country:US
Mailing Address - Phone:813-350-9090
Mailing Address - Fax:
Practice Address - Street 1:2420 W MISSISSIPPI AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-6110
Practice Address - Country:US
Practice Address - Phone:813-350-9090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-22
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS13251207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017868000Medicaid
FLMMBMTOtherBLUE CROSS BLUE SHIELD
FLMMBMTOtherBLUE CROSS BLUE SHIELD