Provider Demographics
NPI:1104963396
Name:CHEN, JESSICA SHY (LAC, DILP OM)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:SHY
Last Name:CHEN
Suffix:
Gender:F
Credentials:LAC, DILP OM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3703 INGLEWOOD BLVD
Mailing Address - Street 2:APT. 204
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-3200
Mailing Address - Country:US
Mailing Address - Phone:310-572-7871
Mailing Address - Fax:
Practice Address - Street 1:1131 WILSHIRE BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-2061
Practice Address - Country:US
Practice Address - Phone:310-917-2200
Practice Address - Fax:310-917-2204
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10684171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist