Provider Demographics
NPI:1003501941
Name:FRIES, JENNIFER RUBY LYNN (NNP-BC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RUBY LYNN
Last Name:FRIES
Suffix:
Gender:F
Credentials:NNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:377 WHIRLAWAY DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95111-2847
Mailing Address - Country:US
Mailing Address - Phone:910-584-8387
Mailing Address - Fax:
Practice Address - Street 1:1500 OWENS ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94158-2334
Practice Address - Country:US
Practice Address - Phone:415-476-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-06
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95024503363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal