Healthcare Provider Details

I. General information

NPI: 1306257167
Provider Name (Legal Business Name): JESSICA K CHU PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2014
Last Update Date: 05/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 W 39TH AVE
SAN MATEO CA
94403-4364
US

IV. Provider business mailing address

222 W 39TH AVE
SAN MATEO CA
94403-4364
US

V. Phone/Fax

Practice location:
  • Phone: 650-573-2222
  • Fax: 650-573-2214
Mailing address:
  • Phone: 650-573-2222
  • Fax: 650-573-2214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number51601
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: