Provider Demographics
NPI:1992765242
Name:NORRIS, JENIFER ELYCE (MD)
Entity type:Individual
Prefix:
First Name:JENIFER
Middle Name:ELYCE
Last Name:NORRIS
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 1:1108 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-3476
Mailing Address - Country:US
Mailing Address - Phone:530-542-5740
Mailing Address - Fax:530-542-5743
Practice Address - Street 1:1108 4TH ST
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-3476
Practice Address - Country:US
Practice Address - Phone:530-542-5740
Practice Address - Fax:530-542-5743
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA60046207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G68655Medicare UPIN