Provider Demographics
NPI:1295101798
Name:CHAN, JEFFREY (LAC)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:
Last Name:CHAN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 E BROADWAY STE 302
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002-6804
Mailing Address - Country:US
Mailing Address - Phone:212-233-0889
Mailing Address - Fax:212-233-0898
Practice Address - Street 1:39 E BROADWAY STE 302
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-6804
Practice Address - Country:US
Practice Address - Phone:212-233-0889
Practice Address - Fax:212-233-0898
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002637171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist