Provider Demographics
NPI:1225670318
Name:NG, JENNIFER RUSNANTO (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RUSNANTO
Last Name:NG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29525 CANWOOD ST STE 200
Mailing Address - Street 2:
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-4230
Mailing Address - Country:US
Mailing Address - Phone:818-699-6553
Mailing Address - Fax:
Practice Address - Street 1:29525 CANWOOD ST STE 200
Practice Address - Street 2:
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301-4230
Practice Address - Country:US
Practice Address - Phone:818-699-6553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-10
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95009670363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily