Healthcare Provider Details

I. General information

NPI: 1568490373
Provider Name (Legal Business Name): JINAE SU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10750 4TH ST
RANCHO CUCAMONGA CA
91730-0979
US

IV. Provider business mailing address

10750 4TH ST BUILDING 1 OFFICE SUITE 150
RANCHO CUCAMONGA CA
91730-0979
US

V. Phone/Fax

Practice location:
  • Phone: 900-476-4456
  • Fax:
Mailing address:
  • Phone: 900-476-4456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA068062
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: