Healthcare Provider Details

I. General information

NPI: 1942123187
Provider Name (Legal Business Name): JENNIFER PHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 ACACIA AVE
SAN RAFAEL CA
94901-2230
US

IV. Provider business mailing address

5 CRESTA CIR APT 5
SAN RAFAEL CA
94903-1911
US

V. Phone/Fax

Practice location:
  • Phone: 415-457-4440
  • Fax:
Mailing address:
  • Phone: 714-386-8855
  • 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: