Provider Demographics
NPI:1073712584
Name:JEN, ANDREW (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:
Last Name:JEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11925 WILSHIRE BLVD
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-6618
Mailing Address - Country:US
Mailing Address - Phone:310-453-2772
Mailing Address - Fax:310-453-3833
Practice Address - Street 1:11925 WILSHIRE BLVD
Practice Address - Street 2:3RD FLOOR
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-6618
Practice Address - Country:US
Practice Address - Phone:310-453-2772
Practice Address - Fax:310-453-3833
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19185103T00000X, 103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic