Provider Demographics
NPI:1952913410
Name:PHAM, JACQUELINE KHANHLINH
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:KHANHLINH
Last Name:PHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10474 LA SOMBRA AVE
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-5211
Mailing Address - Country:US
Mailing Address - Phone:714-906-9915
Mailing Address - Fax:
Practice Address - Street 1:10474 LA SOMBRA AVE
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-5211
Practice Address - Country:US
Practice Address - Phone:714-906-9915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program