Basic Information
| Provider Information | |||||||||
| NPI: | 1578992285 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OWEN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | MADELINE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6900 NW 9TH BLVD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326054251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523336680 | ||||||||
| FaxNumber: | 3523314006 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 MILVIA ST | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947042636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102045514 | ||||||||
| FaxNumber: | 5102045515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2013 | ||||||||
| LastUpdateDate: | 02/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A133751 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | ME153793 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | A133751 | 01 | CA | STATE MEDICAL LICENSE | OTHER |