Healthcare Provider Details

I. General information

NPI: 1245324201
Provider Name (Legal Business Name): JAMES ALLEN JENGO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 09/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 ATLANTIC AVE STE 611
LONG BEACH CA
90813-3414
US

IV. Provider business mailing address

1045 ATLANTIC AVE STE 611
LONG BEACH CA
90813-3414
US

V. Phone/Fax

Practice location:
  • Phone: 562-432-0111
  • Fax: 562-276-0799
Mailing address:
  • Phone: 562-432-0111
  • Fax: 562-276-0799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberG24864
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: