Provider Demographics
NPI:1104387000
Name:SHIN, JENNY JEONGWON (PHARMD)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:JEONGWON
Last Name:SHIN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13117 PORTOLA WAY
Mailing Address - Street 2:
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-3459
Mailing Address - Country:US
Mailing Address - Phone:818-521-9341
Mailing Address - Fax:
Practice Address - Street 1:1509 WILSON TER
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4007
Practice Address - Country:US
Practice Address - Phone:818-409-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH79608183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist