Provider Demographics
NPI:1205155751
Name:MINAMI, JENNIFER (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MINAMI
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:FILE NUMBER 54701
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-4701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1686 BARTON RD
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373
Practice Address - Country:US
Practice Address - Phone:909-558-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-24
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC1573962084P0800X
NY2629402084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry