Provider Demographics
NPI:1205494218
Name:JI, JACK (PHD, FACMG)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:JI
Suffix:
Gender:M
Credentials:PHD, FACMG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 KIMBALL WAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-6218
Mailing Address - Country:US
Mailing Address - Phone:888-268-6795
Mailing Address - Fax:608-541-2450
Practice Address - Street 1:180 KIMBALL WAY
Practice Address - Street 2:
Practice Address - City:SOUTH SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94080-6218
Practice Address - Country:US
Practice Address - Phone:888-268-6795
Practice Address - Fax:608-541-2450
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYJIXXJ1247ZC0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician