Healthcare Provider Details

I. General information

NPI: 1053410027
Provider Name (Legal Business Name): JACQUELINE A. CHANG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9898 GENESEE AVE # AMP615
LA JOLLA CA
92037-1205
US

IV. Provider business mailing address

9898 GENESEE AVE # AMP615
LA JOLLA CA
92037-1205
US

V. Phone/Fax

Practice location:
  • Phone: 858-824-5404
  • Fax: 858-964-3129
Mailing address:
  • Phone: 858-824-5404
  • Fax: 858-964-3129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberG80136
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: