Provider Demographics
NPI:1225211329
Name:MATJAN, SCHAKE JACKIE (PAC)
Entity Type:Individual
Prefix:
First Name:SCHAKE
Middle Name:JACKIE
Last Name:MATJAN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:544 N GLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-3311
Mailing Address - Country:US
Mailing Address - Phone:818-241-4331
Mailing Address - Fax:818-241-2253
Practice Address - Street 1:544 N GLENDALE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-3311
Practice Address - Country:US
Practice Address - Phone:818-241-4331
Practice Address - Fax:818-241-2253
Is Sole Proprietor?:No
Enumeration Date:2007-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19454363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical