Healthcare Provider Details

I. General information

NPI: 1548729692
Provider Name (Legal Business Name): JENNIFER X DUAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: XINYUE DUAN

II. Dates (important events)

Enumeration Date: 03/18/2019
Last Update Date: 03/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 W TAYLOR ST
CHICAGO IL
60612-7232
US

IV. Provider business mailing address

5114 MEDICAL DR APT 2309
SAN ANTONIO TX
78229-3875
US

V. Phone/Fax

Practice location:
  • Phone: 866-600-2273
  • Fax:
Mailing address:
  • Phone: 918-876-2579
  • 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: