Basic Information
| Provider Information | |||||||||
| NPI: | 1609070242 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIOUS | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | PREHN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1245 16TH ST | ||||||||
| Address2: | SUITE 125 | ||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904041235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103194377 | ||||||||
| FaxNumber: | 3103194425 | ||||||||
| Practice Location | |||||||||
| Address1: | 1245 16TH ST | ||||||||
| Address2: | SUITE 125 | ||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904041235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103194377 | ||||||||
| FaxNumber: | 3103194425 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2007 | ||||||||
| LastUpdateDate: | 03/24/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A94614 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A946140 | 05 | CA | MEDICAID |