Provider Demographics
NPI:1982346532
Name:CHAN, JEMIMAH (RD)
Entity Type:Individual
Prefix:
First Name:JEMIMAH
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11027 LINDA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-4751
Mailing Address - Country:US
Mailing Address - Phone:408-497-7424
Mailing Address - Fax:
Practice Address - Street 1:11027 LINDA VISTA DR
Practice Address - Street 2:
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-4751
Practice Address - Country:US
Practice Address - Phone:408-497-7424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-12
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86084885133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered