Provider Demographics
NPI:1558388447
Name:ANDRESEN, JENNIE (MD)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:ANDRESEN
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 1:703 VOLKER HALL
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35294-0001
Mailing Address - Country:US
Mailing Address - Phone:205-934-3795
Mailing Address - Fax:205-975-2499
Practice Address - Street 1:1616 6TH AVE S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-1788
Practice Address - Country:US
Practice Address - Phone:205-939-9585
Practice Address - Fax:205-975-6503
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL17919208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
F84977OtherVIVA
AL009983035Medicaid
AL009983625Medicaid
AL515-26413OtherBC BS
F84977Medicare UPIN
AL009983035Medicaid