Provider Demographics
NPI:1003596743
Name:FAN, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:FAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3924 RESTON CT
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-3946
Mailing Address - Country:US
Mailing Address - Phone:415-408-8281
Mailing Address - Fax:
Practice Address - Street 1:3924 RESTON CT
Practice Address - Street 2:
Practice Address - City:SOUTH SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94080-3946
Practice Address - Country:US
Practice Address - Phone:415-408-8281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-18
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29840235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist