Healthcare Provider Details

I. General information

NPI: 1730993254
Provider Name (Legal Business Name): JACKY ZHU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2025
Last Update Date: 02/05/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12778 SE STARK ST BLDG B
PORTLAND OR
97233-1539
US

IV. Provider business mailing address

11013 SE TAGGART CT
PORTLAND OR
97266-1865
US

V. Phone/Fax

Practice location:
  • Phone: 503-317-3113
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC217573
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: