Provider Demographics
NPI:1881716470
Name:DUFFY, JENNIFER M (PHD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:M
Last Name:DUFFY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:M
Other - Last Name:DUFFY-BELLO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 1126
Mailing Address - Street 2:
Mailing Address - City:LARKSPUR
Mailing Address - State:CA
Mailing Address - Zip Code:94977-1126
Mailing Address - Country:US
Mailing Address - Phone:415-721-9721
Mailing Address - Fax:
Practice Address - Street 1:100 TAMAL PLZ
Practice Address - Street 2:SUITE 107
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925-1125
Practice Address - Country:US
Practice Address - Phone:415-721-9721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17924174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PL179240Medicare ID - Type UnspecifiedPROVIDER #