Basic Information
| Provider Information | |||||||||
| NPI: | 1790172419 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JEN | ||||||||
| FirstName: | DENISE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17234 VALLEY BLVD. | ||||||||
| Address2: | |||||||||
| City: | FONTANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923356847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094275083 | ||||||||
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| Practice Location | |||||||||
| Address1: | 17234 VALLEY BLVD. | ||||||||
| Address2: | |||||||||
| City: | FONTANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923356847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094275083 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2015 | ||||||||
| LastUpdateDate: | 12/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.