Provider Demographics
NPI:1740242874
Name:SHEN, JEN-KWAY (MD)
Entity Type:Individual
Prefix:
First Name:JEN-KWAY
Middle Name:
Last Name:SHEN
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 1:1629 SIALIC PL
Mailing Address - Street 2:
Mailing Address - City:LA HABRA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:90631-8088
Mailing Address - Country:US
Mailing Address - Phone:626-854-2828
Mailing Address - Fax:626-854-2829
Practice Address - Street 1:1850 S AZUSA AVE
Practice Address - Street 2:
Practice Address - City:HACIENDA HTS
Practice Address - State:CA
Practice Address - Zip Code:91745-6813
Practice Address - Country:US
Practice Address - Phone:626-854-2828
Practice Address - Fax:626-854-2829
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44321174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA44321OtherPRIVATE INSURANCE
CA00A443210Medicaid