Provider Demographics
NPI:1184019861
Name:AN, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:AN
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 1:150 HARBOUR WAY N
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94804-2426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 HARBOUR WAY N
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94804-2426
Practice Address - Country:US
Practice Address - Phone:510-237-9537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-31
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125067113208000000X
390200000X
CA162236208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program