Provider Demographics
NPI:1801093570
Name:FAN, JENNIE JESSICA (OD)
Entity type:Individual
Prefix:DR
First Name:JENNIE
Middle Name:JESSICA
Last Name:FAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28281 SOMERSET
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-2889
Mailing Address - Country:US
Mailing Address - Phone:949-581-2239
Mailing Address - Fax:949-472-8163
Practice Address - Street 1:1300 N VERMONT AVE
Practice Address - Street 2:DOCTOR'S TOWER, SUITE 101
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6005
Practice Address - Country:US
Practice Address - Phone:323-667-2102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13246152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist