Provider Demographics
NPI:1124038328
Name:DOUMAS, JENNIFER WOOD (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:WOOD
Last Name:DOUMAS
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 1:10538 MISSION GORGE RD
Mailing Address - Street 2:STE 100
Mailing Address - City:SANTEE
Mailing Address - State:CA
Mailing Address - Zip Code:92071-3154
Mailing Address - Country:US
Mailing Address - Phone:619-456-0033
Mailing Address - Fax:619-456-0095
Practice Address - Street 1:10538 MISSION GORGE RD
Practice Address - Street 2:STE 100
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-3154
Practice Address - Country:US
Practice Address - Phone:619-456-0033
Practice Address - Fax:619-456-0095
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5707207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX57070Medicaid
CAE75205Medicare UPIN
CAW20A5707AMedicare ID - Type Unspecified