Provider Demographics
NPI:1215911045
Name:DELEON, JENNI CONNER (MD)
Entity type:Individual
Prefix:DR
First Name:JENNI
Middle Name:CONNER
Last Name:DELEON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-0000
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:541-266-4579
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-0000
Practice Address - Country:US
Practice Address - Phone:541-267-5151
Practice Address - Fax:541-266-4579
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD25369208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022756Medicaid
OR1407812365OtherNBMC NPI NUMBER-GROUP
OR930635514OtherGROUP TAX ID
ORR0000WFBTVOtherMEDICARE GROUP PIN
ORH47323Medicare UPIN
OR022756Medicaid
ORR0000WFBTVOtherMEDICARE GROUP PIN