Provider Demographics
NPI:1659684322
Name:OBERBECK, JENISA (DO)
Entity Type:Individual
Prefix:DR
First Name:JENISA
Middle Name:
Last Name:OBERBECK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6450 38TH AVE N
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-1645
Mailing Address - Country:US
Mailing Address - Phone:727-545-4444
Mailing Address - Fax:727-545-5855
Practice Address - Street 1:6675 38TH AVE N
Practice Address - Street 2:SUITE 101
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-1594
Practice Address - Country:US
Practice Address - Phone:727-384-1217
Practice Address - Fax:727-384-3240
Is Sole Proprietor?:No
Enumeration Date:2010-07-22
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 11571207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009907800Medicaid