Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251P0200X | Physical Therapist - Pediatrics | 291081 | CA |
NPI | 1023507316 |
---|---|
Provider Name | Jaclyn Chan |
First Address | Los Angeles, CA 90025-3647 |
Second Address | Woodland Hills, CA 91364-6432 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/05/2018 |
Last Update Date | 02/05/2018 |