Provider Demographics
NPI:1215022561
Name:HENRY, JEAN CLAUDE (MD)
Entity Type:Individual
Prefix:
First Name:JEAN CLAUDE
Middle Name:
Last Name:HENRY
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 1:655 S EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-3732
Mailing Address - Country:US
Mailing Address - Phone:909-338-9880
Mailing Address - Fax:909-338-9883
Practice Address - Street 1:655 S EUCLID AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-3732
Practice Address - Country:US
Practice Address - Phone:626-272-7411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA36648208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOA36648OMedicaid
CAA36648Medicare ID - Type Unspecified
CAA28150Medicare UPIN