Healthcare Provider Details

I. General information

NPI: 1396483764
Provider Name (Legal Business Name): JENELLE SKINNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2022
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 GATEWAY BLVD STE 120
SOUTH SAN FRANCISCO CA
94080-7066
US

IV. Provider business mailing address

13424 NW 5TH CT
PLANTATION FL
33325-6145
US

V. Phone/Fax

Practice location:
  • Phone: 650-761-4056
  • Fax: 628-216-8120
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number352274
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95033019
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1175534
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11014809
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: