Healthcare Provider Details

I. General information

NPI: 1588265854
Provider Name (Legal Business Name): JACINDA CHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2020
Last Update Date: 12/23/2021
Certification Date: 12/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1495 RIVER PARK DR STE 200
SACRAMENTO CA
95815-4517
US

IV. Provider business mailing address

1495 RIVER PARK DR STE 200
SACRAMENTO CA
95815-4517
US

V. Phone/Fax

Practice location:
  • Phone: 916-925-7020
  • Fax: 916-925-3680
Mailing address:
  • Phone: 916-925-7020
  • Fax: 916-925-3680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: