Provider Demographics
NPI:1093093171
Name:CHAN, JAIMIE J
Entity Type:Individual
Prefix:MS
First Name:JAIMIE
Middle Name:J
Last Name:CHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 W GRANVILLE AVE
Mailing Address - Street 2:APT 503
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-5200
Mailing Address - Country:US
Mailing Address - Phone:989-309-0691
Mailing Address - Fax:
Practice Address - Street 1:1040 W GRANVILLE AVE
Practice Address - Street 2:APT 503
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-5200
Practice Address - Country:US
Practice Address - Phone:989-309-0691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-24
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program