Provider Demographics
NPI:1417026881
Name:CHAN, JACKIE (DPM)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:CHAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8337 TELEGRAPH RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:PICO RIVERA
Mailing Address - State:CA
Mailing Address - Zip Code:90660-4909
Mailing Address - Country:US
Mailing Address - Phone:562-806-1862
Mailing Address - Fax:562-928-6542
Practice Address - Street 1:8337 TELEGRAPH RD
Practice Address - Street 2:SUITE 206
Practice Address - City:PICO RIVERA
Practice Address - State:CA
Practice Address - Zip Code:90660-4909
Practice Address - Country:US
Practice Address - Phone:562-806-1862
Practice Address - Fax:562-928-6542
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2120213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00021200Medicaid
CAE2120OtherCA MEDICAL LICENSE
E2120Medicare ID - Type UnspecifiedMEDICARE ID #
CA00021200Medicaid