Provider Demographics
NPI:1922232404
Name:VAN WARMERDAM, JENNIFER M (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:VAN WARMERDAM
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 1:3400 DATA DR
Mailing Address - Street 2:ATTN CREDENTIALING/PAYER ENROLLMENT
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 SHRADER ST
Practice Address - Street 2:SUITE 650
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94117-1016
Practice Address - Country:US
Practice Address - Phone:415-221-0665
Practice Address - Fax:415-221-0687
Is Sole Proprietor?:No
Enumeration Date:2009-05-12
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA96120207X00000X
MA239149207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery