Provider Demographics
NPI:1114154861
Name:KRUSE, JENNIFER LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:KRUSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 MEDICAL PLZ
Mailing Address - Street 2:RM 2273
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-6968
Mailing Address - Country:US
Mailing Address - Phone:310-206-8095
Mailing Address - Fax:
Practice Address - Street 1:300 MEDICAL PLZ
Practice Address - Street 2:RM 2273
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-6968
Practice Address - Country:US
Practice Address - Phone:310-206-8095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-19
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1138602084P0800X
MN1067892084P0800X
MN569652084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1114154831Medicaid
MNENROLLEDMedicaid
CAHE814ZMedicare PIN
MN260003886Medicare PIN