MEDICARE: DR. JENNIFER LEE DEPRY D.O.

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	207N00000X	Dermatology Physician	2157	NV
2	207N00000X	Dermatology Physician	20A14883	CA

General Provider Information

NPI Number	:	1619260122
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNIFER LEE DEPRY D.O.

Provider Business Mailing Address
First Line	:	9097 W POST RD
Second Line	:	STE 100
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-2417
Country	:	US
Telephone Number	:	702-430-5333
Fax Number	:	702-430-5335

Provider Business Practice Location Address
First Line	:	1250 S BUFFALO DR STE 170
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-8329
Country	:	US
Telephone Number	:	702-255-7924
Fax Number	:

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

Provider Enumeration Date	:	05/17/2011
Last Update Date	:	02/10/2020

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