Provider Demographics
NPI:1477378198
Name:CHAN, JACKIE FANG-YI (LAC)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:FANG-YI
Last Name:CHAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3178 HOSTETTER RD
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95132-1733
Mailing Address - Country:US
Mailing Address - Phone:408-707-2094
Mailing Address - Fax:
Practice Address - Street 1:100 OCONNOR DR STE 27
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1655
Practice Address - Country:US
Practice Address - Phone:408-831-1038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20077171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist