Healthcare Provider Details

I. General information

NPI: 1215911045
Provider Name (Legal Business Name): JENNI CONNER DELEON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 05/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 WOODLAND DR
COOS BAY OR
97420-0000
US

IV. Provider business mailing address

1900 WOODLAND DR
COOS BAY OR
97420-0000
US

V. Phone/Fax

Practice location:
  • Phone: 541-267-5151
  • Fax: 541-266-4579
Mailing address:
  • Phone: 541-267-5151
  • Fax: 541-266-4579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD25369
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier022756
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 2
Identifier1407812365
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerNBMC NPI NUMBER-GROUP
# 3
Identifier930635514
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerGROUP TAX ID
# 4
IdentifierR0000WFBTV
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerMEDICARE GROUP PIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: