Provider Demographics
NPI:1205064326
Name:DECONDE, JENNIFER BENNITT (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:BENNITT
Last Name:DECONDE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:LOUISE
Other - Last Name:BENNITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4910 DIRECTORS PL
Mailing Address - Street 2:SUITE 250
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-3811
Mailing Address - Country:US
Mailing Address - Phone:858-249-5400
Mailing Address - Fax:
Practice Address - Street 1:4910 DIRECTORS PL
Practice Address - Street 2:SUITE 250
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3811
Practice Address - Country:US
Practice Address - Phone:858-249-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-26
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA108554207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA050262Medicare PIN