Provider Demographics
NPI:1366612749
Name:MICHAEL, JENNIFER B (MD MPH)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:B
Last Name:MICHAEL
Suffix:
Gender:F
Credentials:MD MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 643184
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-8433
Mailing Address - Country:US
Mailing Address - Phone:610-517-4281
Mailing Address - Fax:
Practice Address - Street 1:1600 W AVENUE J
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2814
Practice Address - Country:US
Practice Address - Phone:310-825-2916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-03
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ43677207R00000X, 208M00000X
PAMD438673207R00000X
CAA118026207R00000X, 208M00000X
MI4301097767207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ145954Medicare PIN
AZZ145952Medicare PIN