Provider Demographics
NPI:1396954921
Name:JACKIE T. CHAN, M.D., INC.
Entity type:Organization
Organization Name:JACKIE T. CHAN, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-529-4422
Mailing Address - Street 1:4120 DALE RD
Mailing Address - Street 2:STE J8 #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:209-543-8880
Practice Address - Fax:209-529-1711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG077865261QP3300X, 261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
G00077865Medicare ID - Type Unspecified
G43677Medicare UPIN