Provider Demographics
NPI:1831202092
Name:TAI, JENNY (DO)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:TAI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13299 E. SOUTH ST.
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703
Mailing Address - Country:US
Mailing Address - Phone:562-865-8750
Mailing Address - Fax:562-865-8715
Practice Address - Street 1:13299 E. SOUTH STREET
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703
Practice Address - Country:US
Practice Address - Phone:562-865-8750
Practice Address - Fax:562-865-8715
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8494207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI48199Medicare UPIN
CAW20A8494AMedicare ID - Type Unspecified
CAW20A8494AMedicare ID - Type Unspecified