Provider Demographics
NPI:1003159740
Name:CHAN, JILLIAN K (MD)
Entity Type:Individual
Prefix:DR
First Name:JILLIAN
Middle Name:K
Last Name:CHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:650 HAWKINS AVE STE 7
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-2366
Mailing Address - Country:US
Mailing Address - Phone:631-737-0055
Mailing Address - Fax:631-737-0076
Practice Address - Street 1:650 HAWKINS AVE STE 7
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-2366
Practice Address - Country:US
Practice Address - Phone:631-737-0055
Practice Address - Fax:631-737-0076
Is Sole Proprietor?:No
Enumeration Date:2013-04-01
Last Update Date:2018-10-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY2926522084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology