Provider Demographics
NPI:1770240434
Name:CHAN, JACQUELINE BAYADING
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:BAYADING
Last Name:CHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20639 LEMMER ST
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:CA
Mailing Address - Zip Code:91311-4502
Mailing Address - Country:US
Mailing Address - Phone:818-519-6072
Mailing Address - Fax:818-782-7320
Practice Address - Street 1:8215 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-4810
Practice Address - Country:US
Practice Address - Phone:818-901-0373
Practice Address - Fax:818-782-7320
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-17
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95017629363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty