Provider Demographics
NPI:1376252312
Name:LAI, JENNY
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:LAI
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 1:4193 FLAT ROCK DR.
Mailing Address - Street 2:SUITE 200 OFFICE #498
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505
Mailing Address - Country:US
Mailing Address - Phone:909-910-1680
Mailing Address - Fax:
Practice Address - Street 1:4193 FLAT ROCK DR.
Practice Address - Street 2:SUITE 200 OFFICE #498
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505
Practice Address - Country:US
Practice Address - Phone:909-284-8836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-18
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-12-56306103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst