Provider Demographics
NPI:1528288990
Name:LIM, JENNIFER SIAO (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:SIAO
Last Name:LIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:13437 GLENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-5658
Mailing Address - Country:US
Mailing Address - Phone:818-362-3739
Mailing Address - Fax:
Practice Address - Street 1:15206 PARTHENIA ST
Practice Address - Street 2:
Practice Address - City:NORTH HILLS
Practice Address - State:CA
Practice Address - Zip Code:91343-5305
Practice Address - Country:US
Practice Address - Phone:818-895-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301063957207Q00000X
CAA63309207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104100748Medicaid
MI080H26239Medicare ID - Type Unspecified
MI104100748Medicaid