Provider Demographics
NPI:1104369123
Name:PHAM, JENNIFER (OD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PHAM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8621 MIRANDELA WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-6339
Mailing Address - Country:US
Mailing Address - Phone:408-334-7743
Mailing Address - Fax:
Practice Address - Street 1:1899 W MARCH LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6402
Practice Address - Country:US
Practice Address - Phone:209-623-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-22
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33614152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist