Provider Demographics
NPI:1841375227
Name:CHANG, JENNIFER Y (OD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:Y
Last Name:CHANG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18985 TUGGLE AVE
Mailing Address - Street 2:
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-3658
Mailing Address - Country:US
Mailing Address - Phone:408-255-7785
Mailing Address - Fax:
Practice Address - Street 1:2200 EASTRIDGE LOOP
Practice Address - Street 2:STE 1078
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95122-1410
Practice Address - Country:US
Practice Address - Phone:408-270-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT9658T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU25820Medicare UPIN