Healthcare Provider Details

I. General information

NPI: 1982758884
Provider Name (Legal Business Name): JENNIFER LEE KISSINGER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 01/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 W HIGHWAY 246 STE 102
BUELLTON CA
93427-9458
US

IV. Provider business mailing address

1836 MAGELLAN DR
SANTA MARIA CA
93454-1578
US

V. Phone/Fax

Practice location:
  • Phone: 805-686-8555
  • Fax: 805-686-8556
Mailing address:
  • Phone: 805-928-1491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG55862
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG55862
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG55862
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: