Provider Demographics
NPI:1639181134
Name:KOSTRINSKY, JENNIFER MOREEN (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MOREEN
Last Name:KOSTRINSKY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MOREEN
Other - Last Name:SIMKIN KOSTRINSKY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:5525 GROSSMONT CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3009
Mailing Address - Country:US
Mailing Address - Phone:858-499-2600
Mailing Address - Fax:619-644-6899
Practice Address - Street 1:5525 GROSSMONT CENTER DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3009
Practice Address - Country:US
Practice Address - Phone:858-499-2600
Practice Address - Fax:619-644-6899
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8255207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX82550Medicaid
CA00AX82550Medicaid
CAW20A8255AMedicare ID - Type Unspecified