Healthcare Provider Details

I. General information

NPI: 1568001071
Provider Name (Legal Business Name): JESSICA TAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/31/2019
Last Update Date: 12/17/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1795 2ND ST STE B
BERKELEY CA
94710-1704
US

IV. Provider business mailing address

1795 2ND ST STE B
BERKELEY CA
94710-1704
US

V. Phone/Fax

Practice location:
  • Phone: 510-559-5276
  • Fax:
Mailing address:
  • Phone: 510-559-5276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number81156
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: