Provider Demographics
NPI:1073882270
Name:DAVIS, JENNIFER LYNN (RN)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:SOUTHERN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:415 N SYCAMORE ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-4607
Mailing Address - Country:US
Mailing Address - Phone:714-442-2551
Mailing Address - Fax:
Practice Address - Street 1:415 N SYCAMORE ST STE 200
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4607
Practice Address - Country:US
Practice Address - Phone:714-442-2551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-19
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA805017163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA805017OtherCA BOARD OF REGISTERED NURSING