Provider Demographics
NPI:1053089599
Name:PHAN, JAMIE (MS)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:PHAN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1804 N LIMA ST
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-1526
Mailing Address - Country:US
Mailing Address - Phone:818-531-8805
Mailing Address - Fax:
Practice Address - Street 1:4580 ELECTRONICS PL
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90039-1008
Practice Address - Country:US
Practice Address - Phone:818-531-8805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGC001466170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS