Healthcare Provider Details

I. General information

NPI: 1437330123
Provider Name (Legal Business Name): DR. JACLYN PHAN & ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2007
Last Update Date: 11/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1912 201ST PL SE SUITE 204
BOTHELL WA
98012-8570
US

IV. Provider business mailing address

1912 201ST PL SE SUITE 204
BOTHELL WA
98012-8570
US

V. Phone/Fax

Practice location:
  • Phone: 425-485-6812
  • Fax: 425-485-6813
Mailing address:
  • Phone: 425-485-6812
  • Fax: 425-485-6813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number3357
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2033652
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer

VIII. Authorized Official

Name: DR. JACLYN T PHAN
Title or Position: PRESIDENT
Credential: O.D.
Phone: 425-485-6812