Provider Demographics
NPI:1023193950
Name:TOM, JEAN S (LAC)
Entity Type:Individual
Prefix:MS
First Name:JEAN
Middle Name:S
Last Name:TOM
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 E GREEN ST STE L-10
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-2401
Mailing Address - Country:US
Mailing Address - Phone:626-793-8988
Mailing Address - Fax:626-793-8088
Practice Address - Street 1:960 E GREEN ST STE L-10
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-2401
Practice Address - Country:US
Practice Address - Phone:626-793-8988
Practice Address - Fax:626-793-8088
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 8745171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist