Healthcare Provider Details

I. General information

NPI: 1396954921
Provider Name (Legal Business Name): JACKIE T. CHAN, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 08/24/2023
Certification Date: 08/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 E ORANGEBURG AVE STE A
MODESTO CA
95350-5369
US

IV. Provider business mailing address

4120 DALE RD STE J8 #232
MODESTO CA
95356-9239
US

V. Phone/Fax

Practice location:
  • Phone: 209-543-8880
  • Fax: 209-529-1711
Mailing address:
  • Phone: 209-529-4422
  • Fax: 209-529-1711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberG077865
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License NumberG077865
License Number StateCA

VIII. Authorized Official

Name: DR. JACKIE CHAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 209-529-4422