Provider Demographics
NPI:1063495869
Name:CHAN, JEREMY JAY (DPT ATC)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:JAY
Last Name:CHAN
Suffix:
Gender:M
Credentials:DPT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 SOBRANTE WAY
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94086-4807
Mailing Address - Country:US
Mailing Address - Phone:408-733-3670
Mailing Address - Fax:408-245-7968
Practice Address - Street 1:490 W EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-2610
Practice Address - Country:US
Practice Address - Phone:650-961-7370
Practice Address - Fax:650-961-2360
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT27391225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEO589ZMedicare PIN