Healthcare Provider Details

I. General information

NPI: 1164779419
Provider Name (Legal Business Name): JEANNA LEE SYN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2012
Last Update Date: 09/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 E FOOTHILL BLVD
PASADENA CA
91107-3406
US

IV. Provider business mailing address

12324 ASHWORTH PL
CERRITOS CA
90703-8300
US

V. Phone/Fax

Practice location:
  • Phone: 626-463-1021
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: