Healthcare Provider Details

I. General information

NPI: 1518042977
Provider Name (Legal Business Name): JACKSON CHAU LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4117 JUDAH STREE
SAN FRANCISCO CA
94122-1124
US

IV. Provider business mailing address

4117 JUDAH ST
SAN FRANCISCO CA
94122-1124
US

V. Phone/Fax

Practice location:
  • Phone: 415-566-0832
  • Fax: 415-566-0832
Mailing address:
  • Phone: 415-566-0832
  • Fax: 415-566-0832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License NumberLAC5040
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: