Provider Demographics
NPI:1922264522
Name:WAN, JENNIFER JEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:JEAN
Last Name:WAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168 N BRENT ST STE 508
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-2840
Mailing Address - Country:US
Mailing Address - Phone:805-643-2375
Mailing Address - Fax:805-643-3511
Practice Address - Street 1:168 N BRENT ST STE 508
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-2840
Practice Address - Country:US
Practice Address - Phone:805-643-2375
Practice Address - Fax:805-643-3511
Is Sole Proprietor?:No
Enumeration Date:2008-08-03
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA100066208600000X, 208G00000X
MN63774208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery