Basic Information
Provider Information | |||||||||
NPI: | 1851688295 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHEN | ||||||||
FirstName: | JENNY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4881 NW 8TH AVE STE 2 | ||||||||
Address2: | SUITE 100 | ||||||||
City: | GAINESVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 326054582 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3524017575 | ||||||||
FaxNumber: | 3524017577 | ||||||||
Practice Location | |||||||||
Address1: | 3304 SW 34TH CIR | ||||||||
Address2: | SUITE 101 | ||||||||
City: | OCALA | ||||||||
State: | FL | ||||||||
PostalCode: | 344743358 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3524017575 | ||||||||
FaxNumber: | 3524017577 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/06/2011 | ||||||||
LastUpdateDate: | 08/04/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0505X | ME120738 | FL | Y |   | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine |
ID Information
ID | Type | State | Issuer | Description | ME120738 | 01 | FL | MEDICAL LICENSE | OTHER | HZ578Z | 01 | FL | MEDICARE PTAN | OTHER |