Provider Demographics
NPI:1750977781
Name:CHEN, JACK
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:CHEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13633 37TH AVE FL 7
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-4561
Mailing Address - Country:US
Mailing Address - Phone:917-330-1353
Mailing Address - Fax:
Practice Address - Street 1:13633 37TH AVE FL 7
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-4561
Practice Address - Country:US
Practice Address - Phone:917-330-1353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-14
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028704363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant