Provider Demographics
NPI:1598836793
Name:GAN, JERRY
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:
Last Name:GAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4468 MCDOUGALD BLVD
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95206-6206
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:171 FRONT ST
Practice Address - Street 2:SUITE 101
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94526-3347
Practice Address - Country:US
Practice Address - Phone:925-552-0998
Practice Address - Fax:209-234-6887
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC5324171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist