Healthcare Provider Details

I. General information

NPI: 1871525378
Provider Name (Legal Business Name): JENNIFER M. PUCK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 06/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 FOUTH STREET, 6TH FLOOR IMMUNOLOGY CENTER
SAN FRANCISCO CA
94158
US

IV. Provider business mailing address

550 16TH ST BOX 0434
SAN FRANCISCO CA
94143
US

V. Phone/Fax

Practice location:
  • Phone: 415-502-2090
  • Fax: 415-502-2107
Mailing address:
  • Phone: 415-502-2090
  • Fax: 415-502-2107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG87720
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License NumberG87720
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: