Healthcare Provider Details

I. General information

NPI: 1710973839
Provider Name (Legal Business Name): SANJEEV JAIN M.D.; PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1152 DOUGLAS ST
LONGVIEW WA
98632-2452
US

IV. Provider business mailing address

43575 MISSION BLVD #716
FREMONT CA
94539-5831
US

V. Phone/Fax

Practice location:
  • Phone: 360-940-0880
  • Fax: 844-697-8702
Mailing address:
  • Phone: 360-609-7077
  • Fax: 510-744-9959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberMD00040042
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberG88329
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberMD162938
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: