Provider Demographics
NPI:1710984075
Name:EHMANN, JENNIFER ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ANN
Last Name:EHMANN
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 1:1111 EMERALD BAY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6207
Mailing Address - Country:US
Mailing Address - Phone:530-543-5659
Mailing Address - Fax:530-541-8723
Practice Address - Street 1:2201 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-7025
Practice Address - Country:US
Practice Address - Phone:530-543-5623
Practice Address - Fax:530-541-5738
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11072208000000X
CAA67687208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV100770Medicare PIN
CAXPY202246Medicaid
CA00A676871Medicare PIN
H12672Medicare UPIN
NV100506057Medicaid