Healthcare Provider Details

I. General information

NPI: 1750536793
Provider Name (Legal Business Name): JESSICA B. CHAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2008
Last Update Date: 12/13/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 W MACARTHUR BLVD
OAKLAND CA
94611-5641
US

IV. Provider business mailing address

275 W MACARTHUR BLVD
OAKLAND CA
94611-5641
US

V. Phone/Fax

Practice location:
  • Phone: 510-752-1000
  • Fax: 310-267-2058
Mailing address:
  • Phone: 510-752-1000
  • Fax: 310-267-2058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License NumberA94187
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberA94187
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: