Provider Demographics
NPI:1740534858
Name:ZIDOW, JENNIFER SARAH
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SARAH
Last Name:ZIDOW
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 1:3737 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:550
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-3513
Mailing Address - Country:US
Mailing Address - Phone:310-609-3890
Mailing Address - Fax:310-609-0301
Practice Address - Street 1:1770 E 118TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059-2518
Practice Address - Country:US
Practice Address - Phone:323-249-2950
Practice Address - Fax:323-249-2970
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA191593453251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01245407OtherMEDICAL