Provider Demographics
NPI:1063675106
Name:WILLIS, JENNIFER MICHELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:MICHELLE
Other - Last Name:WILLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:615 E PRINCETON ST STE 401
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-1469
Mailing Address - Country:US
Mailing Address - Phone:407-303-9311
Mailing Address - Fax:407-303-9273
Practice Address - Street 1:615 E PRINCETON ST STE 401
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1469
Practice Address - Country:US
Practice Address - Phone:407-303-9311
Practice Address - Fax:407-303-9273
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ21522080P0210X
IL036 1213162080P0210X
FLME141361208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology