Provider Demographics
NPI:1578839486
Name:LARSEN, JENNIFER JEAN NISSLY (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JEAN NISSLY
Last Name:LARSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:JEAN
Other - Last Name:NISSLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1200 EL CAMINO REAL DEPT 384
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-3208
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 EL CAMINO REAL DEPT 384
Practice Address - Street 2:
Practice Address - City:SOUTH SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94080-3208
Practice Address - Country:US
Practice Address - Phone:650-742-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-25
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA122827207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program