Provider Demographics
NPI:1609571512
Name:SHEN, JERRY
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:SHEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1559 CARNAVON WAY
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95131-2482
Mailing Address - Country:US
Mailing Address - Phone:408-896-7472
Mailing Address - Fax:
Practice Address - Street 1:14445 OLIVE VIEW DRIVE
Practice Address - Street 2:DEPT. OF MEDICINE, RM. 2B182
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342
Practice Address - Country:US
Practice Address - Phone:747-210-3205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-31
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program