Provider Demographics
NPI:1790247120
Name:LE, JENNY C
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:C
Last Name:LE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7945 JACKSON WAY
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-3924
Mailing Address - Country:US
Mailing Address - Phone:714-705-5782
Mailing Address - Fax:
Practice Address - Street 1:15103 HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:LAWNDALE
Practice Address - State:CA
Practice Address - Zip Code:90260-2137
Practice Address - Country:US
Practice Address - Phone:310-679-7619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-04
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57747183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist