Healthcare Provider Details

I. General information

NPI: 1083001143
Provider Name (Legal Business Name): JACQUELINE PENN D.O..
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2015
Last Update Date: 06/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 POTRERO AVE # 6B
SAN FRANCISCO CA
94110
US

IV. Provider business mailing address

4802 10TH AVENUE MAIMONIDES MEDICAL CENTER
BROOKLYN NY
11219
US

V. Phone/Fax

Practice location:
  • Phone: 415-206-5270
  • Fax: 415-206-4722
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number196488853
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number20A16297
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: