Provider Demographics
NPI:1982015210
Name:PHAN, JENNY
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:PHAN
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 1:26520 CACTUS AVE
Mailing Address - Street 2:FAMILY MEDICINE DEPARTMENT
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-3927
Mailing Address - Country:US
Mailing Address - Phone:951-486-5611
Mailing Address - Fax:951-486-5620
Practice Address - Street 1:26520 CACTUS AVE
Practice Address - Street 2:FAMILY MEDICINE DEPARTMENT
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-3927
Practice Address - Country:US
Practice Address - Phone:951-486-5593
Practice Address - Fax:951-486-5595
Is Sole Proprietor?:No
Enumeration Date:2014-05-08
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A13101207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine