Provider Demographics
NPI:1932388659
Name:JENNIFER NGUYEN HUBERT, D.O., INC
Entity Type:Organization
Organization Name:JENNIFER NGUYEN HUBERT, D.O., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:HUBERT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:707-575-3202
Mailing Address - Street 1:1014 HOPPER AVE
Mailing Address - Street 2:# 615
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-1613
Mailing Address - Country:US
Mailing Address - Phone:707-575-3202
Mailing Address - Fax:707-579-8820
Practice Address - Street 1:1014 HOPPER AVE
Practice Address - Street 2:# 615
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-1613
Practice Address - Country:US
Practice Address - Phone:707-575-3202
Practice Address - Fax:707-579-8820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8236207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX82360Medicaid
CAZZZ01799ZMedicare PIN