Provider Demographics
NPI:1154688810
Name:JEN, MAXWELL (MD)
Entity Type:Individual
Prefix:
First Name:MAXWELL
Middle Name:
Last Name:JEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24060 FIR AVE STE A-1
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-2895
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17400 IRVINE BLVD STE N
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3030
Practice Address - Country:US
Practice Address - Phone:111-111-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-19
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA130209207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine