Basic Information
| Provider Information | |||||||||
| NPI: | 1982015210 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHAN | ||||||||
| FirstName: | JENNY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26520 CACTUS AVE | ||||||||
| Address2: | FAMILY MEDICINE DEPARTMENT | ||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925553927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9514865611 | ||||||||
| FaxNumber: | 9514865620 | ||||||||
| Practice Location | |||||||||
| Address1: | 26520 CACTUS AVE | ||||||||
| Address2: | FAMILY MEDICINE DEPARTMENT | ||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925553927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9514865593 | ||||||||
| FaxNumber: | 9514865595 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2014 | ||||||||
| LastUpdateDate: | 12/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20A13101 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.