Provider Demographics
NPI:1215739149
Name:SHIN, JORDAN GAWON
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:GAWON
Last Name:SHIN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:GAWON
Other - Middle Name:
Other - Last Name:SHIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10833 LE CONTE AVE # CHSB2049
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-3075
Mailing Address - Country:US
Mailing Address - Phone:310-825-9111
Mailing Address - Fax:
Practice Address - Street 1:10833 LE CONTE AVE # CHSB2049
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-3075
Practice Address - Country:US
Practice Address - Phone:310-825-9111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-24
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program