Healthcare Provider Details

I. General information

NPI: 1871660480
Provider Name (Legal Business Name): JENNIFER MARIE MCDONNELL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER MARIE FERETICH FNP

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 03/08/2021
Certification Date: 03/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8808 BALBOA AVE
SAN DIEGO CA
92123-1592
US

IV. Provider business mailing address

8808 BALBOA AVE
SAN DIEGO CA
92123-1592
US

V. Phone/Fax

Practice location:
  • Phone: 619-645-0155
  • Fax: 619-645-0193
Mailing address:
  • Phone: 619-645-0155
  • Fax: 619-645-0193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number15817
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number591871
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: