Provider Demographics
NPI:1285684738
Name:DERENNE, JENNIFER L (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:L
Last Name:DERENNE
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 1:401 QUARRY ROAD
Mailing Address - Street 2:
Mailing Address - City:STANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:94305-4837
Mailing Address - Country:US
Mailing Address - Phone:650-723-5511
Mailing Address - Fax:414-456-6259
Practice Address - Street 1:401 QUARRY ROAD
Practice Address - Street 2:
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305-4837
Practice Address - Country:US
Practice Address - Phone:650-723-5511
Practice Address - Fax:414-456-6259
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2171572084P0800X
WI505842084P0800X
CAC549492084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
I53661Medicare UPIN