Provider Demographics
NPI:1730243676
Name:RAPHAEL, JENNY (MD)
Entity type:Individual
Prefix:DR
First Name:JENNY
Middle Name:
Last Name:RAPHAEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 E ROSEVILLE PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3303
Mailing Address - Country:US
Mailing Address - Phone:916-783-7109
Mailing Address - Fax:
Practice Address - Street 1:1620 E ROSEVILLE PKWY STE 200
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3303
Practice Address - Country:US
Practice Address - Phone:916-783-7109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD073232L208000000X
CAA76422208000000X
MA242189208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAH54550Medicare UPIN