Basic Information
Provider Information | |||||||||
NPI: | 1700811312 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JAHNKE | ||||||||
FirstName: | EDWARD | ||||||||
MiddleName: | J | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: | III | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4100 GUARDIAN ST | ||||||||
Address2: | STE 205 | ||||||||
City: | SIMI VALLEY | ||||||||
State: | CA | ||||||||
PostalCode: | 930636717 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8055225940 | ||||||||
FaxNumber: | 8055772018 | ||||||||
Practice Location | |||||||||
Address1: | 501 S BUENA VISTA ST | ||||||||
Address2: |   | ||||||||
City: | BURBANK | ||||||||
State: | CA | ||||||||
PostalCode: | 915054809 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8188476983 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2006 | ||||||||
LastUpdateDate: | 04/01/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | G46668 | CA | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.