Basic Information
Provider Information | |||||||||
NPI: | 1790927887 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TAN | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | LIM | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LIM | ||||||||
OtherFirstName: | JENNIFER | ||||||||
OtherMiddleName: | DESEMBRANA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 928 BROADWAY | ||||||||
Address2: |   | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921015514 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6199773716 | ||||||||
FaxNumber: | 6194813075 | ||||||||
Practice Location | |||||||||
Address1: | 928 BROADWAY | ||||||||
Address2: |   | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921015514 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6199773716 | ||||||||
FaxNumber: | 6194813075 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/03/2009 | ||||||||
LastUpdateDate: | 11/26/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | N |   | Other Service Providers | Case Manager/Care Coordinator |   | 101YM0800X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.