Provider Demographics
NPI:1174775449
Name:BALLINGER, JENNIFER (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BALLINGER
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 1:450 CLARKSON AVE # 1228
Mailing Address - Street 2:DEPT OF EMERGENCY MEDICINE
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-2012
Mailing Address - Country:US
Mailing Address - Phone:718-245-4795
Mailing Address - Fax:
Practice Address - Street 1:450 CLARKSON AVE # 1228
Practice Address - Street 2:DEPT OF EMERGENCY MEDICINE
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2012
Practice Address - Country:US
Practice Address - Phone:718-245-4795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-17
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-064394207P00000X, 207R00000X
NY265780-1207P00000X
CAA111025207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY265780-1OtherNY MEDICAL LICENSE
CAA111025OtherCA MEDICAL LICENSE
IL125-064394OtherSTATE LISCENSE NUMBER