Provider Demographics
NPI:1306399563
Name:RAVEN ACUPUNCTURE CLINIC, INC.
Entity Type:Organization
Organization Name:RAVEN ACUPUNCTURE CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOCELYN
Authorized Official - Middle Name:CHIE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:408-758-2881
Mailing Address - Street 1:1961 PRUNERIDGE AVE
Mailing Address - Street 2:SUITE B1
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95050-6575
Mailing Address - Country:US
Mailing Address - Phone:408-758-2881
Mailing Address - Fax:855-781-8279
Practice Address - Street 1:1961 PRUNERIDGE AVE
Practice Address - Street 2:SUITE B1
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95050-6575
Practice Address - Country:US
Practice Address - Phone:408-758-2881
Practice Address - Fax:855-781-8279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16969171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty