Basic Information
| Provider Information | |||||||||
| NPI: | 1184019861 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AN | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 HARBOUR WAY N | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 948042426 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 150 HARBOUR WAY N | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 948042426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102379537 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2015 | ||||||||
| LastUpdateDate: | 01/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 125067113 | IL | N | Allopathic & Osteopathic Physicians | Pediatrics | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | 162236 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.