Provider Demographics
NPI:1720175862
Name:DAVIS, JENNIFER LISE (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LISE
Last Name:DAVIS
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 1:3160 CAMINO DEL RIO S STE 315
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3835
Mailing Address - Country:US
Mailing Address - Phone:619-377-9909
Mailing Address - Fax:619-378-6596
Practice Address - Street 1:3160 CAMINO DEL RIO S STE 315
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3835
Practice Address - Country:US
Practice Address - Phone:619-377-9909
Practice Address - Fax:619-378-6596
Is Sole Proprietor?:No
Enumeration Date:2006-10-09
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA101027208D00000X, 2080C0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2080C0008XAllopathic & Osteopathic PhysiciansPediatricsChild Abuse Pediatrics