=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851838098
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JIA DI WEN PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2017
-----------------------------------------------------
Last Update Date | 01/26/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5945 W PARKER RD APT 1124
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75093-7759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-268-5765
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5945 W PARKER RD APT 1124
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75093-7759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-268-5765
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246ZG1000X
-----------------------------------------------------
Taxonomy Name | Medical Geneticist (PhD) Specialist/Technologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------