Healthcare Provider Details

I. General information

NPI: 1245812775
Provider Name (Legal Business Name): JACKLYN CHU NEVADO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2021
Last Update Date: 04/23/2021
Certification Date: 04/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7860 GERBER RD
SACRAMENTO CA
95828-4302
US

IV. Provider business mailing address

9712 APPLE MILL DR
ELK GROVE CA
95624-4707
US

V. Phone/Fax

Practice location:
  • Phone: 916-689-8578
  • Fax:
Mailing address:
  • Phone: 916-477-1606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number95237610
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: