Provider Demographics
NPI:1841366804
Name:FAN, JENNIFER (PSYD, LMFT)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:FAN
Suffix:
Gender:F
Credentials:PSYD, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 S B ST
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-4053
Mailing Address - Country:US
Mailing Address - Phone:310-425-3669
Mailing Address - Fax:
Practice Address - Street 1:307 S B ST
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-4053
Practice Address - Country:US
Practice Address - Phone:800-496-3019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47184106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist