Provider Demographics
NPI:1881657872
Name:LOU, JAY JIEKUEN (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:JIEKUEN
Last Name:LOU
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 1:4625 CHURCHILL ST
Mailing Address - Street 2:SUITE 211
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-5868
Mailing Address - Country:US
Mailing Address - Phone:651-765-9800
Mailing Address - Fax:651-765-9801
Practice Address - Street 1:4625 CHURCHILL ST
Practice Address - Street 2:SUITE 211
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-5868
Practice Address - Country:US
Practice Address - Phone:651-765-9800
Practice Address - Fax:651-765-9801
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN38717207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00098375OtherMEDICARE RAILROAD
MN375175000Medicaid
P00098375OtherMEDICARE RAILROAD
MN375175000Medicaid