Healthcare Provider Details

I. General information

NPI: 1811296288
Provider Name (Legal Business Name): JENNIFER PRINCE DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2011
Last Update Date: 05/18/2021
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 N CHINA LAKE BLVD STE 190
RIDGECREST CA
93555-3131
US

IV. Provider business mailing address

2152 REDWOOD CRST
VISTA CA
92081-7381
US

V. Phone/Fax

Practice location:
  • Phone: 760-499-3855
  • Fax: 760-499-3870
Mailing address:
  • Phone: 917-635-1493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20A14479
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number14479
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: