Provider Demographics
NPI:1750674115
Name:LIU, JENNIFER CA-FEN (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CA-FEN
Last Name:LIU
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 E ALMOND AVE
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93637-5606
Mailing Address - Country:US
Mailing Address - Phone:559-675-5512
Mailing Address - Fax:
Practice Address - Street 1:1250 E ALMOND AVE
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93637-5606
Practice Address - Country:US
Practice Address - Phone:559-675-5512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-18
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101019092207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5101019092Medicaid
MI5101019092Medicaid
MI5101019092Medicare PIN