Healthcare Provider Details

I. General information

NPI: 1578839486
Provider Name (Legal Business Name): JENNIFER JEAN NISSLY LARSEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER JEAN NISSLY

II. Dates (important events)

Enumeration Date: 03/25/2012
Last Update Date: 01/10/2022
Certification Date: 06/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 EL CAMINO REAL DEPT 384
SOUTH SAN FRANCISCO CA
94080-3208
US

IV. Provider business mailing address

1200 EL CAMINO REAL DEPT 384
SOUTH SAN FRANCISCO CA
94080-3208
US

V. Phone/Fax

Practice location:
  • Phone: 650-742-2000
  • Fax:
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 Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA122827
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: