Healthcare Provider Details

I. General information

NPI: 1710984075
Provider Name (Legal Business Name): JENNIFER ANN EHMANN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 09/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 SOUTH AVE
SOUTH LAKE TAHOE CA
96150-7025
US

IV. Provider business mailing address

1111 EMERALD BAY RD
SOUTH LAKE TAHOE CA
96150-6207
US

V. Phone/Fax

Practice location:
  • Phone: 530-543-5623
  • Fax: 530-541-5738
Mailing address:
  • Phone: 530-543-5659
  • Fax: 530-541-8723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number11072
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA67687
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: