MEDICARE: DR. JENNIFER MICHELLE WILLIS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	ME141361	FL
2	2080P0210X	Pediatric Nephrology Physician	Q2152	TX
3	2080P0210X	Pediatric Nephrology Physician	036 121316	IL
4	2080P0210X	Pediatric Nephrology Physician	ME141361	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063675106
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNIFER MICHELLE WILLIS MD

Provider Business Mailing Address
First Line	:	615 E PRINCETON ST STE 401
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32803-1469
Country	:	US
Telephone Number	:	407-303-9311
Fax Number	:	407-303-9273

Provider Business Practice Location Address
First Line	:	615 E PRINCETON ST STE 401
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32803-1469
Country	:	US
Telephone Number	:	407-303-9311
Fax Number	:	407-303-9273

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/09/2008
Last Update Date	:	09/13/2024

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