Provider Demographics
NPI:1083001143
Name:PENN, JACQUELINE (DO)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:PENN
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 1:4802 10TH AVENUE
Mailing Address - Street 2:MAIMONIDES MEDICAL CENTER
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1001 POTRERO AVE # 6B
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110
Practice Address - Country:US
Practice Address - Phone:415-206-5270
Practice Address - Fax:415-206-4722
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-16
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196488853390200000X
CA20A162972084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program