Healthcare Provider Details

I. General information

NPI: 1417814286
Provider Name (Legal Business Name): JACKIE A KWOK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 S RAYMOND AVE FL 2
PASADENA CA
91105-3229
US

IV. Provider business mailing address

4140 W 190TH ST
TORRANCE CA
90504-5513
US

V. Phone/Fax

Practice location:
  • Phone: 626-795-8051
  • Fax: 626-795-3056
Mailing address:
  • Phone: 626-795-8051
  • Fax: 626-795-3056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA68593
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: