Provider Demographics
NPI:1558676171
Name:YIP, JACKAI ALEXIS SIOBHAN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JACKAI
Middle Name:ALEXIS SIOBHAN
Last Name:YIP
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JACKAI
Other - Middle Name:ALEXIS SIOBHAN
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8947 N COURTENAY AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-3466
Mailing Address - Country:US
Mailing Address - Phone:909-319-9919
Mailing Address - Fax:
Practice Address - Street 1:5454 EL CAJON BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-3621
Practice Address - Country:US
Practice Address - Phone:619-515-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA154862363A00000X
CA20996363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500639156Medicaid
ORR180457Medicare PIN
ORR180458Medicare PIN
ORR180453Medicare PIN
ORR180454Medicare PIN
ORR180456Medicare PIN
ORR180455Medicare PIN