Healthcare Provider Details

I. General information

NPI: 1912819046
Provider Name (Legal Business Name): JACK THOMAS WESTGAARD-DALY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JACK THOMAS DALY

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

592 RIO LINDO AVE
CHICO CA
95926-1817
US

IV. Provider business mailing address

1310 CLUB DR
VALLEJO CA
94592-1187
US

V. Phone/Fax

Practice location:
  • Phone: 530-552-5058
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: