Provider Demographics
NPI:1801850953
Name:CHAN, JACKIE TSZ-KIT (MD)
Entity Type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:TSZ-KIT
Last Name:CHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4120 DALE RD
Mailing Address - Street 2:STE J-8 #232
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-9239
Mailing Address - Country:US
Mailing Address - Phone:209-529-4422
Mailing Address - Fax:209-529-1711
Practice Address - Street 1:413 E ORANGEBURG AVE STE A
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-5369
Practice Address - Country:US
Practice Address - Phone:209-529-4422
Practice Address - Fax:209-529-1711
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG077865204C00000X, 2081P2900X, 208VP0014X, 208100000X, 171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
BC4731041OtherDEA NUMBER
G43677Medicare UPIN
G00077865Medicare ID - Type Unspecified