Healthcare Provider Details

I. General information

NPI: 1801045158
Provider Name (Legal Business Name): JENNIFER NGOC-SON PHAN PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2008
Last Update Date: 08/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 S DE LACEY AVE STE 110
PASADENA CA
91105-2074
US

IV. Provider business mailing address

210 S DE LACEY AVE STE 110
PASADENA CA
91105-2074
US

V. Phone/Fax

Practice location:
  • Phone: 626-395-7100
  • Fax:
Mailing address:
  • Phone: 626-395-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: