Provider Demographics
NPI:1699101139
Name:TISCARENO, JENNERFER ANDREA (MD)
Entity type:Individual
Prefix:
First Name:JENNERFER
Middle Name:ANDREA
Last Name:TISCARENO
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 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:831-796-1386
Mailing Address - Fax:831-796-1388
Practice Address - Street 1:1441 CONSTITUTION BLVD
Practice Address - Street 2:FLOOR ONE, SUITE 103
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93906-3100
Practice Address - Country:US
Practice Address - Phone:831-755-4123
Practice Address - Fax:831-755-4122
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MS23334207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program