Provider Demographics
NPI:1366465841
Name:MCNEIL, JENNIFER JEANNE (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JEANNE
Last Name:MCNEIL
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 1:3400 DATA DR
Mailing Address - Street 2:PHYSICIAN SUPPORT SERVICES, 2ND FL
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1901 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-6005
Practice Address - Country:US
Practice Address - Phone:209-946-6800
Practice Address - Fax:209-946-6805
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22673208C00000X
CAG127680208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100210840AMedicaid