Provider Demographics
NPI:1750447264
Name:SHIH, JENNIFER (M D)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SHIH
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4124 N.ROSEMEAD BLVD. #A
Mailing Address - Street 2:
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770
Mailing Address - Country:US
Mailing Address - Phone:626-285-2477
Mailing Address - Fax:
Practice Address - Street 1:4124 ROSEMEAD BLVD STE A
Practice Address - Street 2:
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770-4400
Practice Address - Country:US
Practice Address - Phone:626-285-2477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43447261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A434471Medicaid
CA00A434471Medicaid