Provider Demographics
NPI:1982749842
Name:STEWART, JENNIFER L (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:STEWART
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:PO BOX 38
Mailing Address - Street 2:
Mailing Address - City:MENDOCINO
Mailing Address - State:CA
Mailing Address - Zip Code:95460-0038
Mailing Address - Country:US
Mailing Address - Phone:707-937-1055
Mailing Address - Fax:707-937-1061
Practice Address - Street 1:45081 LITTLE LAKE ST
Practice Address - Street 2:
Practice Address - City:MENDOCINO
Practice Address - State:CA
Practice Address - Zip Code:95460-9998
Practice Address - Country:US
Practice Address - Phone:707-937-1022
Practice Address - Fax:707-937-1061
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO44680207Q00000X
ORMD154690207Q00000X
CAA110366207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO76884350Medicaid
CAP01719258OtherRAILROAD MEDICARE
OR500638275Medicaid
ORP01205782OtherMEDICARE RAILROAD
ORR168352Medicare PIN
COC809580Medicare PIN