Healthcare Provider Details

I. General information

NPI: 1346600681
Provider Name (Legal Business Name): JACKIE HUANG NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/29/2016
Last Update Date: 05/05/2023
Certification Date: 05/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 S FAIR OAKS AVE STE 400
PASADENA CA
91105-2684
US

IV. Provider business mailing address

PO BOX 31309
LOS ANGELES CA
90031-0309
US

V. Phone/Fax

Practice location:
  • Phone: 626-568-1622
  • Fax:
Mailing address:
  • Phone: 626-568-1622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number95003794
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: