Provider Demographics
NPI:1710026935
Name:CONNELLY, JENNIFER (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:HSIEH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:5500 E ATHERTON ST
Mailing Address - Street 2:SUITE 416
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90815-4016
Mailing Address - Country:US
Mailing Address - Phone:562-988-0040
Mailing Address - Fax:562-988-0041
Practice Address - Street 1:5500 E ATHERTON ST
Practice Address - Street 2:SUITE 416
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90815-4016
Practice Address - Country:US
Practice Address - Phone:562-988-0040
Practice Address - Fax:562-988-0041
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6896207RE0101X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA20A6896DMedicare ID - Type Unspecified
CAY03913Medicare UPIN