Provider Demographics
NPI:1811296288
Name:PRINCE, JENNIFER (DO)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PRINCE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2152 REDWOOD CRST
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-7381
Mailing Address - Country:US
Mailing Address - Phone:917-635-1493
Mailing Address - Fax:
Practice Address - Street 1:1111 N CHINA LAKE BLVD STE 190
Practice Address - Street 2:
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-3131
Practice Address - Country:US
Practice Address - Phone:760-499-3855
Practice Address - Fax:760-499-3870
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-24
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A14479208000000X
CA14479207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics