Provider Demographics
NPI:1194749556
Name:JENNIFER MAW, M.D., INC
Entity type:Organization
Organization Name:JENNIFER MAW, M.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LESLEY
Authorized Official - Last Name:MAW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-540-5400
Mailing Address - Street 1:3071 PAYNE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-4054
Mailing Address - Country:US
Mailing Address - Phone:408-540-5400
Mailing Address - Fax:408-540-5419
Practice Address - Street 1:3071 PAYNE AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-4054
Practice Address - Country:US
Practice Address - Phone:408-540-5400
Practice Address - Fax:408-540-5419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA657850174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A657850Medicare ID - Type Unspecified
CAG83560Medicare UPIN